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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
= FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�`. «. ! State Farm 43709 (RS / a-03) � �
� Prescribed �y Departmem of Loral Govemment Finance
INSTRUCTIONS: MARF;ie ��05
To be filed in person or by mail with tAe County Auditor of the county where the property is located.
Filing Dates: i) Real Property: During the 12 months before May 11 of the year the deduction is fo 6e eflecti�/
2J Mobile Homes assessed under IC 6-t. l-7: Between January 15 and Ma�ch 2 0! the year the ded ic �s�e effective.
See reverse side for additional instructions and qualifications. a�BSON COUNTY qUDITOR
Applicant (owner or contrac u er - see restrictions on reverse side) ^ ,
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Taxing Distrid number / legal description Record number
5 - �i 9
Page number
�11 D��—�JO3I�(— �
Assessed value of real property as of MoRgage / Contrad indebledness unpaid as of Is the applicant the s e legal or equitable
March t, curcent year March 1, current year owneR es ❑ No
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I( 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 lhat of applicant, indicate below: Is the pro y in question:
eal Property ❑ Mobile Home (IC 61.1-�
��ne of mortgagee or contract seller ���
Address of mortgagee or contract selier (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicanl own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for current yeaf?� Yes❑ No
�� COUNTY AUDITOR
Deduction approve in lhe amounf of:
20 � 20 �� 20 � 20 P� 20 20 20
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Signature County Auditor Date
We certify under the penalty of perjury that the above and foregoing informalion is true and corred and that the applicants was / were
•sident of Indiana and owner of lhe aforementioned property on March t, 20
Signature (owne/s (ull name) Person authorized by duly executed Power of Atlomey
i�( l o� by ic s-i.i-iz-.m
Full resident address of applicant Address of authorized person
X4o�n�, Nu,� s�. F�-an�i,v,cti ,•�,� �7��g