HomeMy WebLinkAboutMortgage_Gray (4)� STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
' ' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
f Slale Fortn 43709 (R4 / 10-01) .
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P�escribeO by DepaNrent W Local Govemment Finance _� �
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INSTRUCTIONS: File Mark
To be filed in person or by mail wifh the County Auditor o/ the county where the property is located. ("��{Y � 9 Z�Q3
Filing Dates: 1) Real Property: During lhe 12 months be(ore May 11 of the year the deducGon is to 6e effective. '
2) Mo6ile Homes assessed under IC 61.1-7: Behveen January 15 and March 31 of C�e year the ded�[ion is fo be'effective.
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See reverse side for additional instructions and qualifications. �J°,��-�-`-t;'
� `� � I„� — I ( - �JOQ OOG o5 �Q� G��,�UT'TY AUDITOR
Applicant (owner or contract buye see restrictig on reversp yide}� ��
Distrid
Key number!
number
i
�O��6a�j7-l� Pagenumber
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the ap�
March t, curtent year 'March 1, cu nt year owne(?
�dSoOa
I( no, what is his / her exad share of interesl? If owned with someone other than sooi
If name on record is different than that of applicant,
of mortgagee or contract seller
Address of mortgagee or contract seller (number
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and st2et,
Does applicant own property in any
county in Indiana?
Deduction approved in the amount of:
20
Signature
state,
ciry, state, ZIP
0
3s i
nt the sole legal or e
❑ Yes ❑ No
indicate with whom.
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❑ Real Property ❑ Mob7e Home QC E1.1-�
If yes, what county? What Taxing Distrid? Has this dedudion been requesled on
property for curtent yeaR � Yes ❑ No
COUNTY AUDITOR
20� „ � 20 n.r � 20
County Auditor
20 D f
�
20 �� 20 0
P P
Date
/ We certify under lhe penalty of perjury thai the above and foregoing infortnation is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
gnature�(owners /ull name) Person authorized by duly executed Power of Atlomey
� U �Q /� - or by IC 6-1.1-12-.07
address of applipnt
of authorized person
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