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�ei'-� � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
I\+�� FOR DEDUCTION FROM ASSESSED VALUATION
`+ ! State Fwm 43709 (R6l 5-06) - . ,
Presaibed by DepaNnent of local Govemment Finance
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INSTRUCTIONS: �p-y�,�., ��w�,�v�,�,
To be filed in person o� by mail with the County Auditor o/ the county where the property is localed. . ".�' (/ -
Filing Dates: 1) Real Property: During the 12 months be%re June Il of the year the deduction is to b�3Nc�0UNTY AUDITOR
2J Mo6ile Homes assessed unde� IC 6-7. 7-7: Between January 15 and March 2 of the year the deduction is fo 6e eHective.
See reverse srde for additional instiuctions and qualifications.
Applicant (owner or contract� Qbuyer - see
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Taxing Disj(�t .
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Assessed value of real property as of
March 1, wrtent year
16 no, whaf is his / her exad share of interest?
tions on reverse side) �
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Key number / legal description Re
2�-iz - e�-io�- o��.
858-0.�-� Pa
Mortgage / Contract indebtedness unpaid as of .
March 1, current year
7 S �oo
e
.. _ .._..._-. O �
: number / 7 / �
.5
Is the applicant the sole legal or equitable
ownef? ' � `❑ Yes � No "
If owned with someone other than'spouse;
If name on record is different than that of applicant, indicate below:
e of mortgagee or contrad Iler
� � ��b� i
Addresa of mortgagee or cont ad seller (number and street, city, state, ""
Name of assignee or
Address
owner or holder of mortgage
(num6erand street, city, state, ZIP
Does applicant own property in any other I If yes, what counry?
county in Indiana?
Deduction
20
Signature
amounl of:
2p O
P
�
❑ Real
with whom.
� Mobile Home pC 61.1-�
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COUNTY AUDITOR
20 20 20
County Auditor
property tor cunent
20
Date
aen requestetl on
�eaR� Yes❑ No
20
certify under the penalty of perjury that the above and foregoing infortnation is true and correct and that lhe applicants was / were
lent of Indiana and owner of the aforementioned property on March t, 20
ue (owne/r�s full ame) /� Person authorized by duly executed Power of Attomey
�. _ 0 J/. �,._ 1' or by IC 6-1.1-12-.07
�u11 rESitlent address of applicant Address of authorized person
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