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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�• ✓ Sute Form 43709 (RS / 4-03)
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� Prescri0ed by Department of Local Govemment Finance T
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INSTRUCTIONS: �� !{ '�� Fil��ar,ii, ��'�
To be filed in person or by mail with the County Auditor of the county where the propeRy is located- �� '� 1:.y
Filing Dates: 1) Real Property: During the 12 months 6efo�e May 11 of the year the deduction is to be e(fective.
2J Mobile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 of the yea�}.�he deduc °`'� to be eflective.
See 2verse side for additional instructions and qualifrcations. ' /�
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Applicanl vnerorcontractbuyer-see�gstnctionsonreversesid ) __ -- --' ' •"""".' '
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Tax� g DistriIX � Key n mber / legal descnption Record number _���
/ ' I v ,� //�j5 _O � 5 � 3 � Page number
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Assessed value of real property as of Mortgage / Contrad indebledness unpaid as of Is the applipnt th le legal or equitable
March 1, cunent 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 that of applicant, indicate below: I property in question:
❑ Real Property ❑ Mobile Home QC 67.1-�
��ne of mortgagee or wntracl seller
3
Address of mortgagee or contrad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage Drawer NO....���.... ..
Address of assignee (numberand street, city, state, ZIP code) Card NO. T�� �
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Does applicant own property in any other If yes, what county? What Ta� 7r� lo V��� �� uested on
county in Indiana? � I Yes❑ No
COUNTY AUDITOR
Deduclion approved in the amount of:
20 � 20 �i � 20 O� 20 �_ 20 20 20
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Signature County Auditor Date
�' We certify under the penalty of perjury that the above and foregoing information is true and corred and thal the applicants was ! were
sident of Indiana and owner of the aforementioned property on March 1, 20
ure (owne s n e) . Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
u I re ent address of applicant Address of authorized person
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