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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�. w� / State Fwm 43709 (RS / 4-03)
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� PrescnEed by Department ot Local Govemment Finance �� i� � (� I� ,
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INSTRUCTIONS: F Mark
To 6e filed in person or by mail with the County Auditor o/ the counry where the property is located. `� U L �� ZUd�t
Filing Dates: 1) Real Property: Dunng fhe 12 months before May 11 of the year the deductioniis to be e!/ective.�j
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2%�he yea.r�tbY deduction is�to 6e eRective.
See reverse side for additional instructions and qualifications. � �'.°-SGt� �;; �`Jp.��-v .�r� �:�`-t�''-�'
Applicant (qwn r or ccyrtract buyer- see restrictions on rever side)
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Taxing D' trid Key number / legal d cri tion Record number
$3 � .-�t _ �i �
Page number ^
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Assessed value of real property s of Mortgage ! Contract indebtedness unpaid as of Is fhe applicant the sole legal or equitable
March 1, curcent year March 1, current year ownef? ��f'es ❑ No
3000
If no, what is his / her exacl share of interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is th�perty in question:
Real Property ❑ Mobile Home QC 61.1-n
�me of mortgagee or contrad seller
Address of mortgagee or contract seller (number and street, ci sta , ZIP
Name of assignee or other owner on c�"—
Address of assignee (num6er and stre �,p �.�i�L�j� ` 1"� �
���p� � ��i
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Does applicant own property in any od ,I� ���. �3i�� �G !na? Has this dedudion been requested on
county in Indiana? . �`T' „_,_._ �/� cc�L -�-� properiy for current year? 0 Yes� No
�.�.�_,��a_vo.o-t' c.-ciiLt�
UNTY AUDITOR
Deduction approved in the amounf :
20 PJ ., 20 � 20 �Q� 20 � 20 20 20
�o P P
Signature County Auditor Dale
�� We certiy under the penalty of perjury thal the above and foregoing information is true and corred and that the applicants was / were
�sident of Indiana and owner of the aforementioned property on March 1, 20
igna e(owners full� Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full resident address of appli Address of authorized person