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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES�
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709 (R6 / 5-06)
Presrnbed by Department of Loral Govemmeni Finaxe
INSTRUCTIONS:
To be filed in pe�son or by mail with the County Audrtor ol the county where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 months before June Il of the year the deduction is to.}��B�ct�✓e?00 �
2) Mobile Homes assessed under IC 6-1.1-7_ Befween January 15 and March 2 o/the year the deduction is to be etlective.
See �everse side for additional instnictions and qualifrcations. aU� �
OI@BO�V�NTY AUDITOR
Applicant (owne�orcont c b er- see 2 rictions on rev r side) �
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Tauing Disirid Key number / legal description Record number Q/�
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�l` a(�-1a-18-1� �o��' ���
Assessed vatue of real property as of Mortgage / Contrad indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, wrtent year March 1, current year owne(? ❑ Yes ❑ No
gsoo
Ii no, whal is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
Ii name on rewrd is differeni than thaf of applicanl, indicate below: Is lhe property in question:
❑ Real Properfy ❑ Mobile Home QC 61.1-�
me of mortgagee or contrad seller ,
ddress of mortgagee or conVact seller (number and street, city, state, ZIP
� Name of assignee or other owner or holder of mortgage
Address of assignee (numberand st2et, city, sfate, ZlPcode)
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduclion been requested on
county in Indiana? property for current yeaf?Q Yes❑ No
COUNTY AUDITOR
Deduction approved in the amounf of:
20 � � _ 20 Q� 20 �� 20 20 20 20
Q � P �
Signature County Auditor Date
'� We certify under the penalty of perjury lhal lhe above and foregoing information is irue and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owne/s full name) Person authorized by duly executed Power of Attomey
�T r by IC 6-1.1-12-.07
F II re�ident address of applicant Address of authorized person
� ap S ou.J- - art 5-�- r'�cefo�