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i i g STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
'i'�; FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
� -.,. _. i State Fortn 43709 (R6 / 5-06) : . . � ' . . . . ,
Prescribed by Oepartment of Lonl Govemment Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail with the CountyAuditor o/the county where the property is locate� ����
Filing Dates: 1J Real Property: Dunng the 12 months be%2 ,lune77 0/ the year the deduction is to 8 ti
.- 2) Mobile Homes assessed unde� IC 6-L 1-7: Between January 15 and March 2 0l th ear c ffecWe.
See �everse side fo� additional instructions and qualifications. NO V 5 L�U �
Applicant ( wnqr or nt ct buye�e resJn
' /`/
I ��
Taxing District
�� �
Assessed value of real property as of
March 1, wrrent year
If no, what is his / her exact share of interest?
If name on rewrd is different than that of appl
�me of mortgagee or contrad seller
reverse
Key number / I�at�te
_ �J
,:�a�_��It
Mortgage / Contrad ii
March 1, curcent year
; .34.<
indicate below:
��
.:� .•r
_�, Page number � CQ 2
J /�,
_ss unpaid as of Is the applicant the sole legal or eqi
owne(? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
Address of mortgagee or conVact selier (number and street, city, state,
Name of assignee or olher owner or holder of mortgage
Address of assignee (n��mh^. --' - -
pRi9Cou-
Does applicant own pro{
county in Indiana?
Deduction approved in lh� ,..,�„un� of:
20
Signature
r� � `
20
PAT Rrc�
B�,Ky
0�1- �5�3
20
County Auditor
at Taxing District7
..,.,ITOR
20
Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.
Has lhis dedudion been requested on
property for wrrent year? 0 Yes ❑ No
�
Date
20
We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
�nature (owners f 11 name) person authorized by duly executed Power of Attomey
� � � �. ���Q or by IC 6-1.1-12-.07
=ull resident address of a�l'cant Address of authorized person
'�' l 11 � � . ��.`- S� .