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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Stata Fortn 43709 (RS / 4-03)
PrescnEed Ey Department of Local Guvemment Finance
Coun Township Year
INSTRUCTIONS: . File Mark
To be filed in pe or by ' rth the County Auditor of the county where the property is located.
Filing Dates: 1) Real Prope : Dunng the 12 montbs 6efore May 11 oI the year the deduction is to be effective. i{ —'�'� �
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of tAe year'th'e deduction is�to be,effe tive.
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See reverse side /or additional instructions and qualifications.
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Applicant (own r ntract buyer - see strictions on reverse side)� � Q �'
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Taxing Disfri Key umber / legal description Record numbei'�,,� �pUN� �"`-
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Assessed value of real property as of MoRgage / Contract indebtedness unpaid as of Is the applipnt the sole legal or equitable
March t, curcent year March 1, cunent year owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone olher than spouse, indicate with whom.
If name on record is dif(erent ihan that of applicant, indicate below: Is the property in question:
� ❑ Real Property ❑ Mobile Home QC 61.1-�
�me of mortgagee or contr s ler / / / �� �pj� � �
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Address of mortgagee or contrad seller (number and stieet, city, s( te, P
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Dislrid? Has this dedudion been requested on
county in Indiana? property for current yeaf? � Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �� 20 �i 20 07 20 �_ 20 0�_ 20 20
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Signature County Auditor Date
i � We certity under the penalty of perjury that the above and foregoing informalion is true and corred and that the applicants was / were
�resident of Indiana and owner of the aforementioned property on March 1, 20
nature (owners Iull name) Person authorized by duly executed Power of Attomey
�� r or by IC 6-1.1-12-.07
F II esid n address ot applipnt j�� �� Address of authorized person
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