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iei� STATEMENT OF MORTGAGE OR CONTRACT INL7EBTEDNESS
'i�' FOR DEDUCTION FROM ASSESSED VALUATION Coun 1 ns ar
J State Fortn 43709 (R6 / 5-06)
� Presoibed by �epartment of Lo�l Govemment Finance
INSTRUCTIONS: �� y��
To be (iled in person or by mail with the County Auditor o/ lhe county where the property is located.
Filing Dates: 1) Real Property: Dunng lhe 12 monlhs befo2 ,lune �7 0/ lhe year lhe deduc6on is to be elf�N COUNTY AUDITOR
2) Mo6ile Homes assessed unde� IC 6-1.1-7: Between January 15 and March 2 0( the year the deduction is to be effect "rve.
See reverse side for additional instnictions and quali/ications.
Applica o erorcontract buyer- see re t' tion on reverse side) ��
T�Distrid ey number / legal description Record number
�� �� a6_oy-a.5-/p/-000.v4�-oa6 pagenumber � �
Assessed value ot real property as of MoRgage / Contrad indebtedness unpaid as of . Is the applicant the sole legal or equitable
March 1, current year March 1, current year owneR ❑ Yes � No
-7 �o0a
If no, what is his / her exad share of interest? If owned wilh someone other than spouse, indicale with whom.
If name on record is difterent than That af applicant, indicate below: Is the property in question:
� ❑ Real Property ❑ Mohile Horne QC Cr1.1-�
e of mortgagee or conVad seller n _
(/ .- �
Address of mortgagee or contraG seller (numb and st2et, city, sfate, ZIP
Name of assignee or other owner ar holder of mortgage
Address of assignee (numberand street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for cunent year? � Yes � No
COUNTY AUDITOR
Deduction approved in the amount of:
20�_ 20 O 20 20 20 20 20
P
Signature County Auditor Date
We certify under lhe penalty of perjury thal the above and foregoing information is true and corred and that lhe applicants was / were
esidenl of indiana and owner of the aforementioned property on MarcFi 1, 20
Si�nat e(owners full name Person authorized by duly executed Power of Attorney
� W o� bY �� 6-,.,-,2-.��
Full resident address of applicanl � Address of authorized person
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