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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION W Tq�wn hi Year
S��.� State Fortn 43709 (R5 / 6-03) J
� RescriDed Dy Depanmem of Local Gdvemment finance
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INSTRUCTIONS: File Ma
To be liled in person or by mail with the County Auditor o/ the county where the property is located. �%6� ��
Filing Oates: 1) Real Property: DunngYhe 12 months be/ore May 11 0l the year the deduction is to be e/fective ��
UNTY, AUQ�TOFi
2) Mo6ile Homes assessed under IC 6-1 JJ: Between January 15 and March 2 0) the y��V��e�ichon �s to 6e eHective.
See reverse side for additional instructions and qual�cations.
Applica (ovmer or contract buyer- see restrictions on reve e side)
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Taxin islriC Key number / legal description Record number
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Page number
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Assessed value of real property as of MoRgage / Contrad indebtedness unpaid as of Is the appliwnt the sole legal or equitable
March i, current year March 1, current year owneR ❑ Yes ❑ No
i� y�
If no, what is his / her exact share of interest? Ii owned with someone olher than spouse, indicate with whom.
It name on rewrd is differeni than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home pC G1.1-n
�me of mortgagee or contrad seiier �/
3
;4ddress of mortgagee or contract seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of�nortgage
Address of assignee (numtier and street, city, state, ZIP code)
Dces�applicant own property in any other If yes, what counry? What Taxing District? Has this dedudion been requested on
county in Irid[ana? � property for.wrrent yea(?� Yes� No
COUNTY AUDITOR
Deduclion approved in the amount of:
zo zo�j� zo 04 2a zo zo zo
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Signature County Auditor Date
� We certify under lhe penalty of perjury that the above and foregoing information is true and corred and lhat the applicants was / were
rasideni of Indiana and owner of the aforementioned property on March 1, 20
S' n t re ners full�) Person authorized by duty executed Power of Attorney
�� or by IC 6-1.1-12-.07
Full re ' address of appl' nt Address of authorized person �
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