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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (R5/4-03)
Prescnbed by Department of Local Govemment Finance
Coun Township Year
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INSTRUCTIONS: Fti ilef May��
To be filed in person or 6y mail with the County Auditor of the county where the property is located. AD R 2 Q Z���
Filing Oates: 1 J Real Property: During the 12 months before May 11 of the year the deduction is to be effective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of t e year the deduyci�ion is tabe ective.
See reverse side /or additional instructions and qualifications. c�,c� c-�c�
� Gi9SON GVOU�i Y AUDIT', � i
Applicant (owne�orcon c u er-see res ion n verse ide)
Taxing Dislrict Key num r/ legal description Record number o
0� D/s/G'�� Page number �
Asses ed value of I prope of Mortgage / Contrad indebtedness unpaid as of Is the applicani the sole legal or equitable
March 1, wrrent year March 1, current year owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than Ihai ot applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC G1.1-�
�'ame of mortgagee or contrad seller
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Address of mortgagee or contract selier (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and stieet, city, state, ZIP code)
Does applipnt own property in any other If yes, what counry? What Taxing Distrid? Has this dedudion been requested on
county in indiana? property for current year? � Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
2o zo 0 4 zo � 2o D F' zo � zo zo
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SignaWre County Auditor Date
�/ We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
, resident of Indiana and owner of the aforementioned property on March 1, 20
Sigr�ture (own s lull Person authorized by duly executed Power of Attomey
��� or by IC 6-1.1-12-.07
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Full re ent address of ppli t Address of authorized person
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