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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S w� / State Fwm 63709 (R5/4-03) �� ��T �
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� Presaibed by Departmem of Local Govemment Finance �
INSTRUCTIONS: JU� � : 20FileMark
To be filed in person or by mail with the County Auditor of the county where the property is located. �
Filing Dates: 1) Real Property: Dunng the 12 months be(ore May 11 0l the year the deduction�is to 6e. elfective� A/!n�
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of.tbe-year fhe�d'eduction-is to be effective.
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See reverse side for additional instructions and qualifications.
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Applican (owner or cont ct b�yer- see 2stncti �s on reyr�rse side)
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Taxing Distrid Key number / legal description Record number //_�//�
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06�_ / _ � Page number
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applican the s e legal or equitable
March 1, current year March 1, current ye2r ownef? es ❑ No
,55s��
If no, what is his / her exact share of interest? if owned with someone other than spouse, indicate with whom.
It name on record is different than that of applicant, indicate be(ow: Is the property in question:
I Property ❑ Mobiie Home (IC 61.1-�
�ame of mortgagee or contreIX seller �/�
Address of mortgagee or contract seller (number and street, city, state. ZIP — — --
Name of assignee or other owner or holder of mortgage
Drawer i\'0 ................:..
Address of assignee (number and street, city, state, ZIP code) . %') �,�//�
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Card NO.�..�� ...:............
Does applicant own property in any cther I I; yes, v+hat counry % � SM;,ai ; ax �� �-�� �_ � -� ed on
county in Indiana7 � � � ;❑ No
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COUNTY AUDITOR
Deduction approved in the amount of:
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Signature County Auditor Date
��/ We certify under the penalty of perjury that the above and foregoing information is true and corred and thal the applicants was / were
. resident of Indiana anC owner of ihe aforementioned property on March i, 20
ig ature (owners (ull name) Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
Full resident address of applicant DSZJ�� ddress of authorized person
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