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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 63709 (R5/4-03)
PrescriDed by Department ol Local Govemment Finance
�TRUCTIONS:
T be �led in person or by mail with the Counry Auditor of tAe county where the property is located. SE � 2(; 200 �t
ding Dates: 1) Real Property: During the 12 months be%re May 11 0/ the year the deduction is to be effective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction�is to 6�e/ eNe�e/tive.
See reverse side for additional instructions and qualifications. �,,,,.~��, .�'�„�,1!,�J
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Applicant(owneror o fract yer-s e st ctiol7�o v eside)
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Taxing Distrid Key nu er / legal description Record number D
(f� / / � / Page number �� �/
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Assessed value of real prope y of Mortgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, cunent year March 1, currenl year ownef? ❑ Yes ❑ No
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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 than that of applicant, indicate betow: Is the property in question:
❑ Real Property ❑ Mobile Horne (IC fr1.1-�
�me of mortgagee or contrad seller
Address of mortgagee or contract seiler (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, sfate, ZIP code)
Does applicant own property in any olher If yes, what county? What Taxing Distric[? Has this deduction been requested on
county in Indiana? property for wrrent yeaf? ❑ YesO No
COUNTY AUDITOR
Deduction approved in the amount of:
20 � 20 D� 20 �_ 20 20 20 20
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Signature County Audilor Dale
�We certify under the penalty of perjury that the above and foregoing information is true and corred and lhat the applicants was / were
esidenl of Indiana and owner of the aforemenlioned property on March 1, 20
Signature ownefs (ull na `_/��� Person authorized by duly executed Power of Attomey
�� j or by IC 6-1.1-12-.07
F�+II _resi nt address f appli nt Address of authorized person
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