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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun ---7ownship' '' Year
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: - «. ! State Fwm 43709 (R5 / 4-03) �� I �.� � � 1 �
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� PrescriDCd by Department ot local Govemment Finance ^^^
AU�7 :. c. LUU�
INSTRUCTIONS: File Mark� /,
To be Iiled in person or by mail with the County Audiror of tbe county where the property is located. � � I! �1�
Filing Dates: 1) Real Property: Dunng the 12 montbs be%re May 11 o/the year the deduction is to be effective'�1/_' MA-r��
i � �c•-r+•� rr�t �
2) Mobile Homes assessed under IC 6-t 1-7: Between January 75 and March 2 0l the year tAe deduction �s to be eflective.
See reverse side for additional instructions and qualiTcations.
Applicant (owner or contract buyer - see restrictions on reverse side)
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Taxing Distrid Key number / legal description Record number Q I
y
Q � � Page number �u �g
•- �
Assessed value of real propeAy as of Mortgage / Contrad indebtedness unpaid as of Is the applica�jt the sole legal or equitable
March 1, current year � March 1, current year owne(? `�T'es ❑ No
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If no, whal is his / her exacl share of interest? If owned wilh someone other lhan spouse, ind(cate with whom.
If name on record is different lhan that of applicant, indicate below: Is the property in question:
�eal Property ❑ Mobile Home pC 61.1-�
"�me of mortgagee or contract seller
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Address of mortgagee contract seller (number and st�eet, city, state, ZIP
Name of assignee or olher owner or holder of mortgage Drawer NO ...................
Q�. 3�,��
Address of assignee (number and street, city, state, ZIP code) Card NO.
Does applicant own propeAy in any other If yes, what county? What Taxing Distric
county in Indiana? �,�„peny tor wrrent yeaR� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 � 20 20 � 20 20 20 20
T
Signature County Auditor Date
�We certify under the penalry of perjury that the above and foregoing information is lrue and correct and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
SignaturQ (own� f name) Person authorized by duly execuled Power of Attomey
/5� �,. or by IC 6-1.1-12-.07
Full resident address of applicant Address of authorized person
�f02 S. Mv... S'�.