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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
: w� / StateFOrtn43709(RS/4-03) � ' . . � �
� PrasaiEetl Ey Department of Lofal Govemment Finance
rNSrRUCnoNS: FEB ��&�
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 fhe 12 months before May 11 of the year the deduction is ro be eH� �
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0( the�BSONe ���to be effective.
See reverse side for additional instructions and quali�cations. COUNTY qUD170R
Appli nt (ow r contract buyer - ee restrictions on re erse sid
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Taxing Distrid Key number / legal descripti Rewrd numbe L1 -���
1
O �_ G� I 1 _ Page number
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Assessed value of real property as of MoAgage / Contract indebtedness unpaid as of Is the applicant the sole gal or equitable
March 1, curtent year March 1, current year owner? ❑ No
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Ii 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 that of applicanl, indicate below: Is the pr erty in question:
eal Property ❑ Mobile Home (IC 61.1-�
�me of mortgagee or contraIX seller
s�3
Address of mortgagee or contract seller (number and street, city, state, ZIP
Name of assigriee or other owner or holder oi mortgage -� - _ _
Address of assignee (number and st2et, city, state, ZIP code)
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S(-I +a tn.' lY��
Does applicant own property in any other I( yes, what county? W � �quested on
county in Indiana? n l� � 1���� ❑ Yes❑ No
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COUNTY AUDITOR
Deduction approved in the amount of:
20 20 � 20 20 0 9 20 20 20
P � P
SignaWre County Auditor Date
�'/ We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Sig ture (owners name) � Person authorized by duly executed Power of Attomey
�or by IC 6-1.1-12-.07
.
II resident address of applicant Address of authorized person