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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VA�UATION
��w� J Sute Fortn 43709 (RS / 4-03)
� PtesrnEe,W 6y Department of Lofal Guvemment Finance
INSTRUCTIONS:
To be �led in person or by mail with the County Auditor of the county where the property is locateo.
Filing Dates: 1J Real Property: During the 12 months be%re May 11 o/the year the deduction is to 6e efiecJig� n��
2) Mobile Homes assessed under IC 6-1.1J: Between January 15 and March 2 of the year the�7e ui�h e eNective.
oee reverse sioe �or aomuona� mswcuons ano quauncauons. �-yy,� ��
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616
Applica wne� or contract 6uyer - see restnctions on reverse s�de -
� e n� �-+ P r �er n� r�s h e► Y►1,
Taxing Distrid Key number / lega6description Record number
�I �on O' —O' �� _ � Page number � � �
\ �' 7
Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, currenl year March 1, currenl year owneR [�Yes ❑ No
$ (o DO
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 than that of applicant, indicate below: Is the property in question:
- Property ❑ Mobife Horrie (IC 61.7-�
�e of moAgagee or contract seller
� ��:.trri�-�.U�111
Address of morigagee or contracl seller (number and st2e7, city, state, ZIP
Name oi assignee or other owner or holder of mortgage
Address of assignee (number and street, ciry, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? propeAy for curtent year? � Yes ❑ No
COUNTY AUDITOR
Deduclion approved in fhe amount of:
20 20 C�J � 20 �� 20 � 20 20 20
� P P
Signature County Auditor Date
� We certify under the penalty of perjury that the above and foregoing information is true and corred and that the appiicants was / were
esident of Indiana and owner of the aforemenlioned property on March 1, 20
Signature (owners (ull name) Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
ull resident address of applicant Address of authorized person
� � .