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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
State Fofm 43709 (R4 I 10-01)
Prespibed by Department d Local Govemment Finance �
INSTRUCTIONS: � � File Mark
To be filed in person or 6y mail with the County Auditor o/ fhe county where the property is Iqq��. 3 � Z��Z
Filing Dates: 1) Real PropeRy: During the 12 monfhs be%2 May 11 0/ the year the deductiorYis to be eflective.
2) Mobile Homes assessed under IC 61.1-7: Between January 15 and March 31 0l the ea �� e de cti is to 6e eHecfive.
See reverse side /or additional instnictions and qualificaUons. ��NT �• pUD��OR
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Applicant (oy�n�i or confract buyer- see resM ions on reverse side)
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Taxing Distrid Key number ega descnption Record number O�
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, cunent year owneR ❑ Yes ❑ No
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If no, what is his / her exad share of interest? It owned with someone other than spouse, indicate with whom.
If name on record is difterent than that of appticant, indicate below: Is the property in question:
❑ Real Property O Mobile Hortie QC Gt.t-�
me of mortgagee or contrad seller
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Address of mortgagee or conVad seller (number and street, city, state, ZIP
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Name ot assignee or other owner or holder of mortgage
Address of assignee (number and street, city, stafe, ZIP code)
Dces applicant own property in any other If yes, what county? What Taxing District'? Has lhis dedudion been requested on
county in Indiana? property for current yeaf?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 0 20 20 Q(� 20 �� 20 � 20 D V
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Signature County Auditor Date
We certify under lhe penalty of perjury that lhe above and foregoing infortnation is lrue and conect and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
ignature (owners full name) Person authorized by duiy executed Power of Attomey
or by IC 6-1.1-12-.07
ull resident address of ap cant Address of authorized person
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