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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
$late FO(m 43709 (R4 ! 10-01) ; .
Prescribed by Departmenl ot Laal Govemmem Fnance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located. F t d 1 4 2003
Filing Dafes: 1) Real Property: Dunng the 12 months before May 11 0/ the year the deduction is to 6e eNective.
2) Mobile Homes assessed under IC 61.1-7: Between January 15 and Ma�ch 31 0/ the year the deduction/ i/s� to be effective.
See reverse side lor additional instructions and qualifications. �, �<-�-� 7�/� n- /n/
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Appli nl owneror'confrac u�- see t tions on reverse sid
Taxi istrid Key number / legal descriplion ecord number �
QQ � �(� 6_ 033o i oo Page number �
Assessed vatue of real prop riy as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curcent year March�nt year ���..'r� owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned wilh someone other than spouse, indicate with whom.
If name on record is diHerent than thaf of applicant, indicate below: Is the property in question:
❑ Real Propeity ❑ Mobile Home QC 61.1-�
"'3me of mortgagee or contrect seiler
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Address of mortgagee or contract seller (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Dces applipnt own property in any olher If yes, what county? What Taxing District? Has this dedudion been requested on
county in Indiana? property for wrtent yeaf? 0 Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
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Signalure County Auditor Date
I/ e certify under the penalty of peryury tha! the above and foregoing information is true and corred and that the applicants was / were
�:esident of Indiana and owner of the aforementioned properiy on March 1, 20
Signature (owners full name) Person authorized by duly exewled Power of Attomey
I or by IC 6-1.1-12-.07
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ull resident address of applipnt Address of authorized person
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