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�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' ;. FOR DEDUCTION FROM ASSESSED VALUATION
S J S�ate Fortn 43709 (R4 / 16-01)
� PrescriDed by DeDartmeM ot Local Govemment Finance
INSTRUCTIONS:
Coun Township Year
File Mark
To 6e filed in person or by mail with fhe County Auditor of the counfy whe2 the property is focated.
Filing Dates: 1) Real Property: Dunng the 12 months be)ore May 11 0/ the year the deduction is to be effective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Befween January 15 and March 31 0l the year the deduction is to 6e effective.
See reveise side for additional instructions and qualifrcations.
Appticanl (own r ntract buyer - see restricfions on rev rse side)
� �� ��
Taui/ng/�Distrid Key number / legal description ' Record nu e
//�Al_,,���, `.Cn � � 00�//` D� Pagenumber �
(/ ✓ .'�v, /% U N- 0� y
Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the a licant the s e I I o e ' e
March 1, currenl year March 1, wrcent year owneR ��1Q�p�7pR ,
/���v G�gcON COU�
`T
If no, what is his / her exacl share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different ihan that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Horne QC 6�1.1-�
�ie of mortgagee or wntrad seller \
Address of moAgagee or contrad seller (number d st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, slate, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for curtent yeaf? O YesO No
COUNTY AUDITOR
Deduction approved in the amounf of:
zo zo 0 zo Zo v� zo O' zo � zo o�
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Signature County Auditor Date
Ne certify under the penalty of perjury that the above and foregoing infortnation is true and correct and that the applicants was / were
asideni of Indiana and owner of the aforementioned property on March 1, 20
Si nature (owners full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full resident dress of appli nt — Address of authorized person