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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 437 W(R5 / 4-03)
PrescriDtd by Department o1 Local Guvemmeni Finance
Coun Township Year
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INSTRUCTIONS: Fi�e(p��c �. jUO3
To be �led in person or by mail with the County Auditor of the county where fhe property is located. j`�
Filing Dates: 1) Real Property: During the 12 months be(o2 May 11 of the year the deduction is to be eBectiw� �� n ///���
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and Marcb 2 of the year the deduction`.ls;to.be,eflectiv_e"!�
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See reverse side for additional instructions and quali�cations. �� GIBSON CGU,:� * aUDiTOR
Applicant (owner or cont ct buyer - see restrictions on reverse side)
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Taxing Disirid Key number / legal description Record number
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Page number
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, wrrrent year owne(? ❑ Yes ❑ No
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If no, what is his / her exacl share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different ihan that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home QC 61.1-�
��me of mortgagee or conlract seller �
Address of mortgagee or contract seiler (number and stieet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand street, city, state, ZIP code)
Does applicant own property in any olher If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for current year?Q Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
20 � 20 20 Li � 20 � 20 �_ 20 � 20
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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 that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1. 20
ignature (owners full name) Person authorized by duly executed Power of Attomey
' w or by IC 6-1.1-12-.07
Fu{FrQS� enl address Of a plican ^ �� Addr� s of authorized person
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