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`° �� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
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INSTRUCTIONS: D E C L� FL� +�.i�
To be filed in person or by mail with fhe County Auditor o! fhe county where fhe property is located.
Filing Dates: 1) Real Property: Dunng f6e 12 months before May 11 0/ the year ffie deduction is�to be eflecti�e. �� �i �.
2) Mobile Homes assessed under IC 6-1.1-7: Befween January 15 and March 31 o('the year.the'deduction is to be eHective.
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See reverse side (or additional inshuctions and qualifications. G!�3SO�i CCU'! i Y hUDiTCR
Applicant (ownero�confract buyer- see restrictions on reverse
Taxing Dislrid
� 1`�1 oh"�" o v�efi
Assessed value of real property as oi
March 1, wrtent year
If no, what is his / her exacl share of
name on record is different lhan tha
ame of mortgagee or contract seller
Address o( morig6ge
21 5
Name of assignee or
of assignee
Key number / legal desuiption
�
�03_70
DD � D� �_ O 5) Page number �
C/
Mortgage 7 Conlract indebtedness unpaid as of Is the appticant the e legal or equitabl�
March 1, wrtent year owneft es ❑ No
' l ! 7 DOt�, Oa
If owned with someone other than spouse, indicale with whom.
indicate below:
or conlrad seller (number and street, ciry, state, ZIP
2 ti J S i�. ��f v� S V i���
owner or holder oj mortgage
city, state, ZIP
❑ Real Property ❑ Modle Home QC 6-1.1-�
7 7a :�
Does applicant own property in any other If yes, what county? What Taxing Distrid7 Has this dedudion been requestetl on
county in Indiana7 property for current year?� Yes❑ Nc
Deduction approved in the amounl
20 jL� 20
P-�i�e o
Signalure
COUNTY AUDITOR
� `✓' 20 � �0 20 �
Y � Y
County Auditor
20 �e
20 O `I 20
Date �
I/ We certify under the penalry of pe�jury.thal lhe above and foregoing infortnation is true and corred and lhat the applicants was / were
�' a residenl of Indiana and owner of the aforementioned property on March 1, 20 .
Signature (owners (ull name Person authorized by duly executed Power of Atlomey
\,� 1. n0� w—R �� ar by IC 6-7.1-12-.07 � —
X
Full resident address ot applicant
of authorized person
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