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�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 'Tajqwrl5hip ar
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� Presaibed by Depariment of Loml GovemmeM Finance -
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INSTRUCTIONS: File' � Q�
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: i) Real Property: Dunng the 12 months befora ,lune Il of the year fhe deduction is to be e/fective',!BSON COUNTY AUDITOR
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is fo be eAective.
See reverse srde for additional instructions and qualifications.
Applicant wnerorcontract buyer- see 'c6on on reverse side)
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Taxing Distri ey number / legal description Record number
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�le-la-O'1-4aa�aoo- ���"�Oa'� Pagenumber � � ' I
Assessed vatue of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curcent year March 1, curtent year owneR ❑ Yes ❑ No
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Ii no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is difierent ihan that of applicani, indicate below: Is the property in queslion:
Pro{�ty ❑ Mobile Home QC 61.1-�
e of moAgagee ar contrad seiler
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Address of mortgagee or conVad seller (number a street, city, stafe, ZIP —
Name of assignee or other owner or holder of mortgage Dt•a ��'�r l�i�.:: Y::Y, ,(`; ,,7.( ��
Cat'(j 1 ` •
Address of assignee (num6er and st2et, city, state, ZIP code) � �. :. .......
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Dces applicant own property in any other If yes, what counry? What Taxing Distrid? �a� .� __� requested on
county in Indiana? property for curcent yeaR � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amounl of:
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Signature County Auditor Date
We certiy under the penalty of perjury lhat the above and foregoing infortnation is true and corred and that the applicants was / were
sident of Indiana and owner of the aforementioned property on March 1, 20
ignature (owners full name) Person authorized by duly executed Power of Attorney
� j �� � or by IC 6-1.1-12-.07
Full'�ident address of appli t Address of authorized person
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