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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VAIUATION
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J. State Fortn 43709 (RS / 4-03)
Prescnbea by Departmem of Local Govemment Finance
INSTRUCTIONS:
To be filed in person or 6y mail with the County Auditor of the county where the property is locateo.
Filing Dates:: f) Real Property: During the 12 months be%re May 11 0! the year the deduction is to be e//ecgy�,l ������
2)�Mobile Homes assessed under IC 6-1J-7: Between January 15 and March 2 o)the year the `�edu i e el%ctive.
See reverse side f�r addifinnal in.ctnmfinns and niwlifica�innc
G�l� ,a �
Appiicani (owner or contracf buy see resMctions on reverse side)
Taxing Distrid Key number / legal description Rewrd number �
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� _6 ) _ � Page number ��
Assessed value oi real property as of Mortgage ! Contract indebtedness unpaid as ot Is the applicant the sole legal or equitable
March 1, current year March 1, current year owner? I�A'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.
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If name on record is different than that of applicanf, indicate below: 's the property in question:
O�EaI Property O Mobile Hmie QC 61.7-�
�me of mortgagee�or contraIX seiler
Address of mortgagee or contrad seller (number and street, city, state, ZIP C./� � ,5�� o o„ ,.,
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Name ot assignee or other owner or holder of mortgage DI���A6 ��
Address of assignee (numberand street, city, state, ZIP code)
p I�' `��- U S- U��{-S
Does applicant own property in�any other If yes, what county? What Taxing District? Has this deduction been requested on
coun�y in Indiana? - property for wrrent year? � Yes ❑ No
St COUNTY AUDITOR
Deduction a roved in t e amount of:
zo �_ 20 �_ 20 0 9 20 20 20 20
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Signature County Auditor Date
We certify under the penalty of peryury that the above and foregoing infortnation is true and correcl and that the applicants was / were
a resident of indiana and owner of the aforementioned property on March 1, 20
Signature (owners (ull name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full re ident address of applicant - Address of authorized person
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