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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�• ,«• ! Sute Fwm 637p9 (RS / d-03)
� Prespi�etl Dy Department of Laal Govemmenl Finance
INSTRUCTIONS: � (� +( �'� File Marfc
To be filed in person or 6y mail with the County Audiror of the county where the propertyLlocated. l,f j,�"� ��� �
Filing Dates: 1) Real Property: During the 12 months be%re May 11 0l the year the deduction is'to tie'effective' �
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2�h,e year the deducfion is to be eHective.
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Applicant (ownerorcont buy r- e resM n on �verse side) �r°S�'�i COUn�j-� kUDI�^-�� � i�
Taxing D" d Key number / legal description Record number D
��Q D�- ao 5 36 age number
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Assessed value of real propeAy as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, currenl year ownef? ❑ Yes ❑ No
O �O�
If no, what is his ! her exaci share of interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is differenl lhan ihat of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC &1.1-�
�me of mortgagee or contracl seller
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Address of mortgagee or wntrect seller (number and street, city, ate, ZIP ���� ��
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, ciry, state, ZIP code)
Does applicant own property in any other If yes, what wunry? What Taxing Distrid? Has this dedudion been requesled on
county�in Indiana? property for current yearl � Yes� No
COUNTY AUDITOR
Deduction approved in the amounl of:
20��_ 20 20 �g� 20 20 20 20
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Signature County Auditor Date
� We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
2sident of Indiana and owner of the aforementioned property on March 1, 20
Sign �u� (o ers full nar�e) Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
F Il r sident a ress of applicanl J Address of authorized person
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