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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�• � � J Sute Fom: 43709 (RS / 4-03) ' � � . . t . ' . � .
� PmsaiGed by Department of Local Govemmeni Finance
INSTRUCTIONS: . File Mark ^��
i
To be filed in person or by mail with the CountyAuditor o/the county where the property is located. � . ,� �
Filing Dates: f) Real PropeRy: Dunng the 12 months be%re May 11 0/ the year the deduction is to be eKective. """� � �
2J Mo6ile Homes assessed under lC 6-1.1-7: Between January 15 and March 2 0/ the year the deductlon�i� t�be eflective.
See reverse side for additional instructions and qualifications. U 2��4
� 10�1.'3r�e� � e��� ��� • 0� � �n0�.. . -��_..�! . Y] n ..
(owner or contract
Taxing Distnd –
.
Assessed value oi real property as of
March t, current�year
on reverse side)
Key number / legal description
0 03 - 0 000/ o�
Mortgage / Contract indebtedness unpaid as
March 1, current year . -
��p40
Record
Page number
Is the applicant lhe sofe legal or equitable
owneR ❑ Yes ❑ No
If no, what is his / her exact share of interesl? 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 PropeAy O Mobile Hmie (IC 61.1-�
'ame of moRgagee or contract seller �J��
Address of,mortgagee or contract seller (number and street, city, state. ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city. �fate, ZIP code)
Does applicanl own property in any ether I If yes, what county? I1'Vhai Taxing Distrid?
county in Indiana?
Deduction approved in the amount of:
20
Signature
20 �6
COUN iY AUDITOR
20 �Q� 20 �� 20
—/ �
County Auditor
Has this deduciion been requested on
property for current year? n Yes ❑ No
20
Date
�
/ We certify under the penalty of perjury that the above and feregoing information is true and corred and that the applicants was / were
: residen,of Indiana and owner o( the aforemer.tioned property on March t, 20
name)
Person auihorized by duiy executed Power of Attorney
or by IC 6-1.7-12-.07
Full resident address of applicant _ �Address of authorized person