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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
State Fwm 437W (R5/4-03) � � � �--.�
Prescri�ed Gy Departmem o( Local Govemment Finaxe ? � E[�
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INSTRUCTIONS: A�R 2� ZO�i�e Mark
To be filed in person or by mail with the County Auditor of [he county where the propeRy is loeated.
Filing Oates: 1J Real Property: During the 12 months belae May 11 0/ the year the deduction'rs to be e�fle'ctive� n //
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March�rt'6fthe�year,-the deductio�s td%e effective.
61ES6N COUNTY AU��T^". �
See reverse side !or additional instructions and qualifications. �
Applicant(owne� rco t2ctb yer- e io o�ver ide/�� � ��i�.��l'J' "'� Q
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Taxing Distri Key number / legal description Record number �
�O� �O ^1�q � Page number �0�
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Assessed value oi real prope as of Mortgage / Contred indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, ear i�� �37 owneR ❑ Yes ❑ No
� St� c�O G - /� ao? - a -�. % �" -aa�
If no, what is his / her exact share of interest? ( owned with someone other than spouse, indicate with whom.
If name on record is different than lhat of appiicant, indicate below: Is the property in question:
❑ Real PropeAy ❑ Mobile Hmie (IC 6-1.1-�
�ame of moRgagee or wntract seller
✓ Address of moAgagee or contrad seller (number and st2et, c� state, ZIP �
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for current year? � Yes❑ No
COUNTY AUDITOR
Deduction approved in lhe amount of:
20 0 20 20 � 20 20 � 20 � 20
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Signature County Auditor Date
/ We certify under the penalry of perjury that the above and foregoing information is true and corred and that the applicants was / were
i resident of Indiana and owner of the aforementioned property on March t, 20
' Signature (owne/s (ull name) person authorized by duly executed Power of Attomey
� or by IC 6-1.1-12-.07
F 11 resident address of applicant Address of authorized person
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