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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (R5/ 4-03)
P25aiEed by Department of Local Govemment Financa
INSTRUCTIONS:
Coun Township Year
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g .1L� .1.LJ �Li�
File Ma
To 6e filed in person or by mail with the County Auditor o! the county where the property is located. '� U � ����3
Filing Dates: 1J Real Property: Dunng the 12 months belore May 11 of the year the deduction is to 6e eflective.
2) Mobile Homes assessed under IC 6-1.1J: Between January 15 and March 2 of the ,��%,a�r the deductioni�s�to� b�e(/eN�ec(/tive.
See reverse side for additional insLuctions and ualifrcations. /� ��`���'r --'"��
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Applicant owne�orcontract buyer- see restrictions on reverse side)
Tauing Distrid Key number / lega� description Record number
, Page number
0 oob 3$
Assessed value of real property as of Mortgage / Contred indebledness unpaid as of Is the applicant the sole legal or equitable
March 1, wrrent year March 1, current year owneR [�'es ❑ No
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If no, what is his ! her exact 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 properfy in question:
eal Pmpeiiy ❑ Mobile Hane (IC 61.1-�
me of mortgagee or contract selier
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Address of mo agee or contract seller (number andstreet, city, stat Drawer NO...�.�— 7���
Name of assig� oth wner or holder of mortgage
C.�{� Card NO . .....................
/ - —
Address of assig e(number street, city, sfate, ZIP code)
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Does applicant ow perty in any other If yes, what county? What Taxing Dislrid? Has lhis dedudion been requested on
county in Indiana? property for current year? 0 Yes � No
COUNTY AUDITOR
Deduction approved in fhe amount of:
20 O 20 �j"� 20 20 � 20 �_ 20 �_ 20
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Signalure County Auditor Date
•' We certiy under the penalty of perjury that lhe above and foregoing infortnation is true and corred and that the appiicants was / were
�esident of Indiana and owner of the aforementioned property on March 1. 20
Signatur (owners fullname) Person authorized 6y duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full resid address of applicant Address of authorized person
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