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e�' � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�s> � FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
J StaleFwm43709 (R615-06)
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Presmbed by Department af Laal Gwemment Finance �, � � �
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iNSrRUCrioNS: APR ���(i�17
To be filed in person o� by mail wdh the County Audito� o/ the county whe�e the property is located.
Filrng Dates: i) Real Property: During the 12 months 6efore June il o/ fhe year the deduction is to be eHective.
2) Mobile Homes assessed under IC 6-1.7-7: Between January 15 and March 2 o(the year th�io�$i�n,be e(fective.
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See reverse side for addftional instroc6ons and qualifications. OIBSON C6ll�fi�f RUB�dR
Applicant (ow � oi contract buyer - see rastnctions on reverse ' e) (
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Taxing District Key nu r I al description Record number ��O n
y���T �la'�� ��-�07�-0�• //a?- Pagenumber '/
Assessed value of real property as of MoRgage / Contract 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 exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that oi applicant, indicate below: • Is the property in question:
0 Real Property � MobBe Home QC G1.1-�
�e of mortgagee or contract seiler �� __
Address of mortgagee or contract seiler (nu ber and s[reet, city, stafe, ZIP Dra�ti��C
n'0.:��........
Name oT assignee or other owner or holder of mortgage Card 1\'� :-`��y �'
Address of assignee (numbe� and stieet, city, state. ZIP code) ���i� p(�, a? ���"""
Does applicant own property in any ottier If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for wrrent yeaR ❑ Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 0 20�_ 20 f7 20 20 20 20
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Signature County Auditor Date
I I We certify under the penalty of perjury ihat the above and foregoing infortnation is We and correct and that the applicants was / were
sident of Indiana and owner of [he aforementioned property on March t, 20
ur owne/s full na e) Person authorized by duly executed Power of Attomey
,' .,�,/ or by IC 6-1.1-12-.07
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Full resident address o applicant Address of authorized person
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