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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS --� �
' FOR DEDUCTION FROM ASSESSED VALUATION u�1t � Township `,- Year
'v� M� / Sute Fortn 43709 (R5 / 4-03) , Y .�.J � �
� Prescn�etl by Department of Loral Gtivemment Finance O C
U
INSTRUCTIONS: �� ���
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 mont6s belore May 11 of the.year the deduction is to �CdN67ue±TV au9�76R
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction is to be ef(ective.
See reverse side Por additional instiuctrons and quali(cations.
confract buyer- s�ejresMctions on
Key nurpber / legal description � Record
L���' _"" - Y.� �' `�`i � �-CJ / Q � `-' `i Page number � /
Assessed vatue of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant lhe sole legal or equitable
March 1, curtent year March 1, current year ownef? ❑ Yes ❑ No
�v �
If no, what is his / her exact share of interest? If owned with someone otner than spouse, indicate with whom.
��f. Gi���e3— O �6�-
I name on record is different ihan that of applicanl, indicate below: Is the property in question:
of mortgagee or contrad seller
Address ot mortgagee or contract seller (number and
oi assignee or other owner or holder of mortgage
� LJ Fteal.em^-�— (IC 61.1-�
--"� � No...�cQ`i•.......
Drawer
� ���
city, state, ZIP .•
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county?
county in Indiana?
' I
Deduction approved in the amount of:
20 Q� 20 � 20 �
� � �
Signalure
Card r�'�� �
-��°g`"-`� - . - --
What Taxing District? Has this deduction been requested on
property for current year? � Yes ❑ No
COUNTY AUDITOR
20
County Auditor
�
20
Date
20
We ceAi(y under the penalty of perjury ihat the above and foregoing information is true and corred and that the applicants was / were
esident of Indiana and owner of the aforementioned propeRy on March 1, 20
�gnatu� (ow s full name�� Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
of
0
of authorized person