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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
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��� Presaibed by Depertment ot Local Govemment Finance "�'�-.j y � !{ � �''
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INSTRUCTIONS: �J(JN ����r_k
To be filed in person or by mail with the County Auditor o! the county whe�e the property is located. � 4
Filing Dates: 1) Real Property: During the 12 months belore May 11 0/ the year the deduction is to be eflective. � �/
2J Mobile Homes assessed under IC 6-1 J-7: Between January 15 and March 2 0/ the�year the;deduction!is to be%ffective.
See reverse side for additional instroctions and quali�cations. /� ��5�� ��'L� `��^�*�-`��
A licant (owner or confract 6uyer - se s nctions on reverse si
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Tax�a�,Disjrict Key n / legal desaiption Record number �^ I
I� a CvCJ
� � �� a � G-� Page number �^ r,, L
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Assessed value of real property as of Morlgage / ContreG indebtedness unpaid as of Is the applicant the sol legal or equitable
March 1, wrrent year March 1, wrrent ye2r owneR es ❑ No
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If 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 ap�licant, indicate below: Is the property in question:
eal Property ❑ Mobile Home (IC 61.1-�
�ame of mortgagee or contract seller
Address of mortgagee or contract seller (number and street, city s te. ZIP
Name of assignee or other owner or holder of mortgage �
�/ ��'
Address of assignee (num6erand sfinet, cit�, state, ZIP code) `t
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Does applicant own property in any other If yes, what county? l^Jh�'T2xing Districl? Has this deduction been requested on
county in Indiana? i property for current yea(? ❑ Yes ❑ No
COUNTY AUDITOR
Deduction approved in fhe amount oi:
zo �� zo 6 20 0 7 20 �_ zo o Y zo zo
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Signature County Auditor Date
�/ We certify under the penalty of perjury lhat the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the atorementioned property on March t, 20
Sign� wners 11 na e) Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
Full resident a ess of applicant Address of authorized person