HomeMy WebLinkAboutMortgage_Rybacheki��* STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
� FOR DEDUCTION FROM ASSESSED VALUATION� �ry( � C n 7ownship Year
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! State Form 43709 (R6 / 5-OG) Q�'1 �
� Pre5m6ed by Oeperiment af Loral Gwemment Finarrce L
APR 1
INSTRUCTIONS: � Fite Mark
To be Tled in person or by mail with lhe County Auditor ot the county whe�e the prope �y� t�
Filing Dates: 1) Real Property: Dunng tbe 12 months befoie June I7 of the year the deAuction tPp�,�OL�d58e.
2) Mobile Homes assessed unde� IC 6-1.1-7: Between January 15 a�gTPii��he yea� the deduction is to be elfective.
See �everse side for additional instructions and qualifications.
Applican (o e� or cont2ct b�r - ses re trictions on reve se sid
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Taxing District Key number / legal descri n Record number
� QD C�� ^� ,� Page number
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Assessed value of real property as of Mortgage / ConVact indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year M 1, rren e � Q Yes � No
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If no, what is his / her exact share of interest? wned with someone other than spouse, indicate with whom.
I( name on record is difterent than that of applicant, indicate below: Is the property in question:
❑ Real Properry � Modle Fbme QC 6�1.1-�
�e of mortgagee or contract seller
Address of mortgagee or contract seller (number and stieet, city, state, Z/P
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Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state. ZIP code)
Does applicant w✓n property in any other If yes, what county? What Taxing DistricY? Has this deduc6on been requested on
county in indiana? property for current year? ❑ YesO No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �� 20 20 20 20 20 20
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Signature County Auditor Date
I/ We certify under the penalry of perjury that the above and foregoing infortnation is We and conect and that the applicants was / were
ident of Indiana and owner of the aforementioned property on March 1, 20 .
i ure (own /s full e) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Ful residen� address of appli t Address of authorized person
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