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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Sute Fortn 43709 (R5/ a-03) .
Presrn0ed by Department of Lowl Gdvemment Finance
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INSTRUCTIONS: Fi�le! "M�ark
To be filed in person or by mail with the Counry Auditor of fhe county where the properfy is located. '�'jJ�„o. ,an�.
Filing Dates: 1J Real PiopeRy: Dunng the 12 months before May 11 01 the year the deduction is to be c�flective TY AVp�T�q-
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of ti�gl�C+4YMf%��uct�on �s to be ef/ective.
See reverse side for additional instructions and qualifications
A plica er or contiacf buyer- see �re/stricti on reverse side) �C�'—^� •' -`—"Y' .
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Taxing islrid Key number / legai description Rewrd number /'
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Page number
Assessed value of real property as of MoAgage / Contract indebtedness unpaid as of Is lhe applican sole legal or equitable
March 1, current year MarcFi 1, wrrent year owneR es ❑ No
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It no, what is his / her exacl share of interesl? If owned with someone other lhan spouse, indicate with whom.
If name on record is different than ihat of appliwnl, indicate below: Is the property in question:
� ❑ Real Property ❑ Mobile Home (IC G1.1-�
��me of mortgagee or contrad seller
Address ot mortgagee or contred seller (number and stieet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address�of assignee (numberand street, city, state, ZIP code) �
Does applicant own properiy in any other if yes, what wunty? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for current year?�] Yes� No
COUNTY AUDITOR
Deduclion approved in the amount of:
20 20 D� 20 � 20 20 20 20
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Signature County Auditor Date
' We certify under the penalty of perjury that the above and foregoing iniormation is true and correct and that the applicants was / were
. resident of Indiana and owner of the aforementioned property on March 1, 20
�Sig ture (o_wnersiul�name) ��T,`� »'t/l� Person authorized by duly executed Power of Attomey
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d �v � or by IC 6-1.1-12-.07
Full sident ddress o( pplicant Address of authorized person