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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709 (RS / 4-03)
PrescriDed by Depertment af Local Govemment Finance
Coun Township Year
INSTRUCTIONS: File Maric
To 6e filed in person or by mail with the County Auditor of the county where the p y is l� e�
Filing Dates: 1J Real Property: During the 12 months before May 11 a/the a t d ucho �is�° ective.
2) Mobile Homes assessed under IC 6-1.1-7: Between Janua� an�P�ir� 2 oI the ear the deduction is to be efiective.
See 2verse side for additional instructions and qualifrcations. � 0��
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Applicant o ner or contract buyer - se Mcfions on reverse side) �'� i J���-�� R,
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Taxin District Key number / legal description � u°^ Record numberO �
D� C%�� �/ / O � O / �� � Page number � �
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, current year owner? ❑ Yes ❑ 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 applicant, indicate below: Is the property in queslion:
❑ Real Property ❑ Mobile Home (IC 61.1-7)
�ime of mortgagee or contract seller � � `
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Address of mortgagee or contract seller (number and street, city, s ate, ZIP
Name of assignee or other owner or holder ot mortgage
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Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county7 What Taxing District? Has this deduction been requested on
county in Indiana? property for curtent year? ❑ Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
20 Q� 20 �J,� 20 20 20 �� 20 0 9 20
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Signature County Auditor Date
/ We certify under the penairy of perjury that the above and foregoing information is true and correct and that the applicants was ! were
'esident of Indiana and owner of the aforementioned property on March 1, 20
'g ature (owner's /ull e) �j Person authorized by duly executed Power of Attomey
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Full resideni address of appli nt Address of authorized person
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