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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
: ��� ! State Fortn 43709 (RS ! 4-03)
� PmscriDed Dy Department of Lorai Govemment Finance
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INSTRUCTIONS: ��� F.ile Ma� ic J
To be filed in person or by mail with the County Auditor of the county where the property is located.i �' �� J_� j,..�'
Filing Dates: 1) Real Property: Dunng the 12 months belore May 11 0/ fhe year the deduciion is.to 6e eHective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the ye�c��e didt�cfto'��is to be elfective.
See reverse side fnr addifinnal insfmclinns and m�al�relinnc
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Applicanl owner contracf 6uyer- see restdctions on rev e side) �gS0�1 COU: ���� �`��'' �"'
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Taxing Dislrid K y number / legal description Record number Q�
G��1,� ` C /'��/i— � /0 � �V � � � -� Page number �i �/O �
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Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, current year /rj, � Q��r ownef? ❑ Yes � No
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If no, what is his / her exact share of interest? Ii owned wilh someone other than spouse, indicate with whom.
If name on rewrd is different than lhat of applicant, indicate below: Is the property in question:
❑ Real Propert�r O Mobile Home (IC 61.1-�
3me of mortgagee or contrad seller
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Address of mortgagee or conVad sefier (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and st�eet, city, state, ZIP code) �
Does applicant own propeRy in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? ` property for current yeaR O YesO No
COUNTY AUDITOR
Deduction approved in fhe amount of:
20 20� 20 � 20 20�� 20 20
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Signature County Auditor Date
�We certify under the penalty of peryury that the above and foregoing informalion is true and corred and lhat the applicants was / were
residenl of Indiana and owner of the aforementioned property on March 1, 20
Signat re (owners full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full resident address of applicant Address of aulhorized person
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