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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
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� PrescriDeO by Department o( Loral Govemment Finance � J
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INSTRUCTIONS: APR 2 ZOO�F File Maric
To be filed in person or 6y mail with the CountyAUditor of the counry where the property i�-located. n
Filing Dates: 1J Real Property: During the 12 months before May 11 0/ the year the deduEtion is to be eflec�e. Q (/
2) Mobile Homes assessed under IC 6-1J-7: Between January 15 and MarcA2�of the y �-tlie dedu`c;kon"i's to be effective.
See reverse side for additional instructions and qual�cations.
Applicant (ow rorFqntrac u� - see restrictions on verse side)
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Taxing Dislrid number / legal description Record number �
� �I /_ ^ y�o �—� Pagenumber
10 11
Assessed value oi I property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owneR ❑ Yes ❑ No
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If no, what is his / her exad share of interest? 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:
❑ Real Property ❑ Mobile Hane (IC 61.1-�
�ame of mortgagee or contred seller � �
Address of mortgagee or contrect seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP code)
Does applipnt own property in any other If yes, what wunty? What Taxing District? Has this dedudion been requested on
county in Indiana? property for current year? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �,� 20 20 �Z 20 �� 20 O 20 20
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Signature County Audilor Date
I/ e certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
�i esident of Indiana and owner of the aforementioned property on March 1, 20
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ignature (owners full ame) Person authorized by duly executed Power oT Attomey
or by IC 6-1.1-12-.07
Full resident ad r s of applicant Address of authorized person
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