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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS •
FOR DEDUCTION FROM ASSESSED VALUATION o ow ..hip Year
S J State Fortn 43709 (RS / 4-03) -- , � ,
�, Prescribed Oy Depanment of Loral Govemmem Finance MAR Y Z0�6
INSTRUCTIONS: �(o•� �i�¢-ylark
To be filed in person or by mail with the County Auditor of the county where the property is locat U U
PUIBSON CpUNfiV AU6ifi@b
Frling Dates: 1J Real Property: During the 12 months before May 11 of fhe year the deduction is to be e/fective.
2) Mobile Homes assessed under lC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction is to be effective.
See reverse side for additional instroctions and qualifications.
Applicant (ownero ontract 6uyer- see rest�cti s on re s side)
Taxing Dislri ey number / legal escription Record number
�/9 ��7's� �� Pagenumber �
/ �
Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant t e sole legal or equitable
March 1; wrrent year March 1, current year owner? ❑ Yes ❑ No
/ - � .
( (� YJv
If no, what is his / her exact share of interest? f owned with someone other than spouse, indicate with whom.
If name on record is different ihan lhat of appiicant, indicate below: Is the property in question:
❑ Real Propsty ❑ Mobile Home QC 61.1-�
�me of mortgagee or contrad seller �
�
Address of mortgagee or contract seller (number and et, city, state, ZIP
Name of assignee or other owner or holder of mortgage � .
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this dedudion been requested on
county in Indiana? property for currenl yeaR� Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
20 � 20 �_ . 20 � 20 20 20 20
� i
Signature County Auditor Date
�We certify under the penalty of perjury lhat the above and toregoing infortnation is true and wrred and thal the applicanls was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners full name) Person authorized by duty executed Power of Attorney
��. C� ,` .� ' or by IC 6-1.1-12-.07
Full resident address of applicant Address of authorized person