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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�+ � «� / State Form 63709 (RS / 4-03) � . - --^"1 �
��' PraSfiiped by Department o1 Local Guvemment Finance
INSTRUCTIONS: FEB O Fle 4�A'�tk
To 6e filed in person or by mail with lhe County Auditor of the county where the property is located.
Filing Dates: 1 J Real Property: Dunng the 12 months 6efore May 11 of the year the deduction is to be e(/ecti�ve^ ¢��,
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduct�on is fo 6eery ective.
See reverse side for additional instructions and qualifications. di850N COUNTY AUDITOR
nNpnwni �uwrmi u�
ig Distrid
�W "
�uyer-
Assessed value of real property as of
March i, wrrent year
on reverse slde)
Ke�umber / legal description Record numb�
�� -/� -oz - 30� - 000. �/q - o a S
�' n _ /�� n ,Q� Page number
�T �J `-[
MoAgage / Contrad indebtedness unpaid as of Is the ap�
March 1, current year owneR
If no, what is his / her exact share of interest?
If name on record is differeni than that of applicanl, indicate
of moAgagee or contraIX seller
Address of mortgagee or contrad seller (number and sfreet,
Name of assignee or other owner or holder of mortgage
of assignee (number and st�eet, city, state, Z1P code)
1 the sole legal or equitable
❑ Yes ❑ No
It owned with someone other than spouse, indicate with whom.
Does appiicant own property in any other If yes, what counry? What Taxing Distrid?
wunty in Indiana?
COUNTY AUDITOR
Deduction approved in the amount ot:
20 � 20 �
� �.
Signature
20 �_ 20 20
/
County Auditor
Is the
❑ Real Property ❑ Mobile Hane (IC 61.1-�
Has this dedudion been requested on
property for current yeaR 0 Yes 0 No
�
20
ify under the penalty of perjury that the above and foregoing information is true and correcl and thal lhe applicants was / were
of Indiana and owner of the aforementioned property on March 1, 20
name)
A �
Person authorized by duty executed Power of Attomey
or by IC 6-7.7-12-.07
Full resident aAdress d�bplic�t v Address of authorized person