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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
SUte Fofm 43709 (R4/ 16-07)
Presuibea by DeDartmenl of Loral Govemment Finance
Coun Township Year
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INSTRUCTIONS: " File Mark
To be filed in person or 6y mail with the County Auditor of the county whe�e the property is located. ���HK 1� 2��3
Filing Dates: 1) Real PropeRy: During the 12 months before May 11 of the year the deduction is to 6e ef/ectivey,
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 31 of the year the dKe,�ductio,�n �,is to, b�e%��{He�ctive/�. � �//]
See reverse side /or additional inst�uctions and qualifrcations. ,!�Y - J� ";'�"'�"` �'""f
GIB�Oii Ct,U� • � UDITO� ,
Applicanl (owne� or contract buyer- see restrictions on reverse s
Taxing Distrid ey number / legal description Record number
03
rt ^ � _ � (� ' Page number
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equilable
March 1, wrrent year March 1, current year owneR �es ❑ No
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If no, what is his / her exact share of interest? If owned with someone ather than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
Real Property ❑ Modle Home pC 61.1-�
^�ame of mortgagee or contract seller
Address of mortga ee or contraIX seller (number and street, city, state, ZIP
Name of assignee or olher owner or holder of mortgage
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Address of assignee (number and st2et, city, state, ZIP code) j /
Does applipnt own property in any other If yes, what county? What Taxing Distrid? Has lhis deduclion been requested on
county in Indiana? property for curcent yeaR � Yes � No
COUNTY AUDITOR
Deduction approved in the amounl of:
20 �� zo �� zo v� zo � 2o Q� zo �� zo 0 9
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Signature County Auditor Date
/ We certify under the penalty of perjury that the above and foregoing infortnation is lrue and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners /ull name) Person authorized by duly executed Power of Attomey
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Full resi ent address of applipnt Address of authorized person
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