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ie',i ^ STATEMENT OF MORTGAGE OR CONTRACT INDEIBTEDNESS
`� FOR DEDUCTION FROM ASSESSED VALUATION Co t Year
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Prescribetl by Department of Lopl Gwemmenl Finance r:U � 9 2�� I
INSTRUCTIONS: ��' �e ric
To be Iiled in person or by mail with the County Audifor of the county whe�e the propeRy is Iocate��BS�N COUNTY��ITOR
Filing Dates: 1) Real Property: During the 12 months before ,lune ! 1 0/ the year the deduction is to be e/fective.
2J Mobile Homes assessed under IC 6-1.1 J: Between January 15 and March 2 of lhe year the deduc6'on is to 6e eBective.
See reverse side for additional instnictions and qualifrcations.
Applicant (owner or contract buyer- see trictions on reverse side)
Taxing Distrid ' . ' Key number / legal description ' Record number
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a�_�� _a y_�_�. o�v -0� age number
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Assessed value oi real property as of Mortgage / Contred 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 exad share of interest? If owned with someone other lhan spouse, indicate with wnom.
If name on record i t than that of applicanl, indicate below: Is the property in quesiion:
eal Propaty ❑ Mobile Hmie (IC 6-1.1-�
e of mort gee r contrad seiler
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Address of mortgagee or conVad seller (number and st2et, city, state, ZIP •
Name o( assignee or other owner or holder of mortgage
Addresa of assignee (num6er and st2ef, city, state, ZIP code)
Does appGcant own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in �ndiana? property for cunent yeaR � Yes ❑ No
COUNTY AUDITOR
Dedudion approved in the amount of:
20�_ 20�� 20 20 20 20 20
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Signature County Auditor Date
We certity under lhe penalty of perjury that the above and foregoing infortnation is true and correct and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
ignature (owners (u11 name) Person authorized by duly executed Power of Attomey
�_ � or by IC 6-1.1-12-.07
Full resident address of applipnt Address of authorized person
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