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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortr 43709 (RS I 4-03)
Presuibed by Depanmeni ot Loral Govemment Finance
Coun Township Year
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INSTRUCTIONS: Fjle(� rk
To 6e filed in person or by mail with the County Auditor of [he county where the property is located. i�� ���� ��uJ
Filing Dates: 1) Real Property: During the 12 months before May 11 0l the year the deduction is to.be eRective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 oI the year the ded� hon is t fbe eflective.
See reverse side Ior additional instnictions and qualifications. ��"`^'`�1 Y � 707 '
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Appiicant (ovmer or co trac uyer-, see restn ' ns on �pvefse side) � � ���`�
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Ta�cing Disiricl Key number / legal description Record number �
� Q'� ,,., QD�I/��� Pagenumber
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Assessed val�e of real property as of Mortgage / Contract indebtedness unpaid as of Is the applica e sole leg or equitable
March 1, current year March 1, currenl year owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interesl? If owned with someone other than spouse, indicate with whom.
If name on record is different lhan that ot applicant, indicate below: Is the property in question:
❑ Real Properiy ❑ Mobile Home QC 61.1-�
�me of mortgagee or contrad selier �
Address of mortgagee or conVact seller (number and street, city, state, ZIP
Name of assignee or olher 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 deduction been requested on
county in Indiana? property for curcent yeaR � Yes❑ No
COUNTY AUDITOR
Deduction approved in the amounl of:
20 Q� 20 �� 20 6� 20 (-T 20 Q� 20 �L 20
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Signature County Auditor Date
We ify under the penalty of peryury that the above and foregoing informalion is true and corred and that lhe applicants was / were
. resi nt of Indiana and owner of the aforemenlioned property on March 1, 20
Si ure (owners full name) Person authorized by duly execuled Power of Atlorney
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F II r ident addre of a'cant Address of authorized person