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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
` / Stzte Fortn 43709 (RS / 4-03) �[��' �f �''� �7-�
� PrescriDed Cy Departmetrt o1 Local Go•iemment Finance En � JJ /�j,� � q p
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INSTRUCTIONS: NOV j ���a�
To 6e filed in person or by mail with the County Auditor of the county wheie the property is located.
Filing Dates: 1 J Real Property: Dunng the 12 months be(ore May 11 0/ the year the deduction is to 6e e/fective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the yeai the'deductron:is to 6e eHective.
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See reverse side for additional instructions and qualifications. COUNTY AUDITpR
Applicant (owne� o ntracf buyer - see restrictio on reverse "de
Taxing Disirid e number / legal description Record number
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Assessed value oi real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrrent year March 1, current year ownef? [�Yes ❑ No
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If no, what is his / her exacl share of interesl? Ii owned with someone other than spouse, indicate with whom.
If name on record is different Ihan ihat of applicant, indicate below: Is the property in question:
�eal PropeAy ❑ Mobile Home (IC 61.1-�
�me of mortgagee or contrad seller ��� . .
Address of moAgagee or contract selier (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage . DraWer �� �0��;,� (�O�
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Address of assignee (number and street, city, state, ZIP code)
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Does applicant own property in any other If yes, what county? What Taxing ed on
county in Indiana? piupr��y ��� ...����.. �..,... .� ._>� No
� COUNTY AUDITOR
Deduction approved in the amount of:
20�� 2o f�_ 20 09 20 20 2o zo
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Signalure County Auditor Date
We certify under the penalty of perjury thal lhe above and foregoing infortnation is true and corred and that lhe applicants was / were
residenl of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners full n e) Person authorized by duly executed Power of Attomey
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Full resident address of lipnt ' Address of authorized person
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