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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
•� S p� � State Form 43709 (RS / 4-03) q�
Presai�ed Dy Departmem of Local Govemment Finance �
� TRUCTIONS: � � File Mark
To be filed in person or 6y mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real PropeRy: During the 12 months before May 11 0/ the year the deduction is to be e/%ctive.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is to be effective.
See reverse side for additional instructions and qualifications.
Applicant (owner or contract boyer- see resMctions on reverse�ide)
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Taxing Dislrid Key number / legal description Record number
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Page number
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Assessed value of real property as of Mortgage / Contrect indebtedness unpaid as of Is the applipnt the sole legal or equitable
March 1, curtent year March 1, current year owneR �Yes ❑ No
If no, what is his / her exact share of interest? If owned wilh someone other than spouse, indicate wilh whom.
If name on record is different than Ihat ot applicant, indicate below: Is the property in question:
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❑ Real Property ❑ Mobile Home (IC G1.1-�
Name of mortgagee or contract seller
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Address of moAgagee or contrad seller (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage r(1- I/ -O �
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Address of assignee (number and st�eef, city, state, ZIP code)
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Does applipnt own property in any other If yes, what counry? What Taxing Distri '1 equested on
county in lndiana? , p h�1 /�-)/_ 0� ❑ Yes❑ No
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COUNTY AUDITOR
Deduction approved in the amount of:
20 li 20 20 Q(� 20 �� 20 � 20�5 20
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ignature (,.J County Auditor Date
I/ We certify under the penalty of perjury that the above and foregoing information is irue and corred and that the applicanls was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
ignature (ownefs tull name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full resident address of applicant Address of authorized person