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Ja�' °. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
'i.`�:= FOR DEDUCTION FROM ASSESSED VALUATION Coun Tcwnship Year
y State Fortn 43709 (R6 / 5-06)
� I� Prescribetl by Department of Lopl Gwemment Finance
INSTRUCTIONS: (� � �F�a�
To be filed in person or by mail with the County Auditor of the county where the p�operty is localeoa �� �j�
Filing Dates: 1) Rea( P�operty: Dunng the 12 months before ,lune 17 of the year the deduction is to be elfective.
2) Mobile Homes assessed unde� IC 6-1.1J: Between January 15 and March 2 o(the year��le�c7io�(j�i7o 6e effective.
See reverse side for additional instructions and qualifications.
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Applica (ownerorcontract uyer-se st� on reverse side) ON COUNTY AUDITOR
Tauin Distrid Key number / legal description Record number � Q � /
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�Y��+L���/75•� 16 � d-07 -�O y- oOd _ d' 4�8 -8 Page number !� n a�
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Assessed value of real property as of MoRgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March t, current year March 1, current year owner? ❑ Yes ❑ No
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If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of appticanf, indicate below: L ----��--'�^^=-,----��,
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�me of mortgagee or contrad seller ��� .
Address of mortgagee or contraG seller (number and street, city, state, � �•
Name of assignee or other owner or holder of mortgage �{���
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Address of assignee (number and street, city, state, ZIP code) /� �^
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Dces applicant own property in any other If yes, what county? � 7O?/ ��'° n
munty in Indiana? Vo
i
COUNTY � � O � � � � � �
Deduction approred in the amount of:
��P-/a-o-r, yoY- o��, d"l�-oa-P
20 ��j_ zo�$_ 20 09 Zo __
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SignaWre Couniy Audilor Date
/ We certify under the penalry of perjury that the above and foregoing information is lrue and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signa� (owners me) Person authorized by duly executed Power of Attomey
(_ ,t� or by IC 6-t.t-12-.07
Full ident address of applicant Address of authorized person
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