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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
SUIe Fwm 43709 (R4 / 10-01)
Prescnbe0 by DepaNrenl of Lotal Govemment Finance
INSTRUCTIONS: '
To be filed in person or by mail with the County Auditor o/ the county where the property is located. Hr R Z j 2003
Filing Dates: 1) Real Property: During the 12 months before May 11 ot the year the deduction is to be eflective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 31 of the yeIa/� the deduction is'tb be elfectiv .
See reverse side lor additional instructions and qualifrca6ons. /�7�'� ''`�� ��j,���
/° (iICSON C�OUhTY AUDITOR
Applicant ( er or contract buyer- see restri ' s on re rse side)
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Taxing DisUi Key number / legal description Record number
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Page number
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March i, current year Marr,h 1, current year owner? ��s ❑ No
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If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicanl, indicate below: Is the p perty in question:
�Properly ❑ Mobile Hane (IC 61.1-�
�ame of mortgagee or contrad seller {/3
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Address of moRgagee or conVact seller (number and street, city, sfate, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and streef, city, state, ZIP code)
Does applipnt own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for current yeaf?� YesO No
x� a3����v COUNTYAUDITOR ��
Deduction approved in the amount of:
20 20 D 20 20 20 � 20 �� 20 ��
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Signature County Auditor Dale
I/ We certify under the penalty of perjury that the above and foregoing infortnation is lrue and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned propeRy on March 1, 20
Sig alure (owners full name) Person authorized by duly executed Power of Attomey
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or by IC 6-1.1-12-.07
Fuil re dent addr ss of applipnt Address of aulhorized person
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