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A rt•n STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
- �: FOR DEDUCTION FROM ASSESSED VALUATION _ Count Township Year
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� Prescribe0 by Department of Local Govemmeni Finance N
Su �ect o ina�ac�ep e ransfer
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INSTRUCTIONS: File Mark
To 6e (led in person or by mail with the County Auditor o/ the county whe2 the property foc t � �� A�ditor
Filing Dates: 1) Real Property: Dunng the 12 months belo2 May 11 0l the year the ded yg,�_ ���,�4'�nty
2) Mobile Homes assessed under IC 61.1-7: Behveen January 15 and M���P�Rte �eattf%ie"dedudtton is to be eHective.
See reverse side (or additional instructions and qualifrcations.
Applicant (owner or contia buyer- see restri� s on reve�e side� �
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Taxing Dist 'd Key number / legal description Record number �
�� Q I U_ O�� ]( _/—� Page number �
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Assessed value of real property as of Mortgage / Contred indebtedness unpaid as of Is the appli nt e sole legal or equitable
March 1, curtent year March 1, current year ownef? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other lhan spouse, indicate with whom.
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If name on record is different than that of applicant, indicate below: Is e propeRy in question:
❑ Real Property ❑ Mohile Hane QC Cr1.1-�
�ame of mortgagee or contrad seller
Address of mortgagee or contrad seller (num an s reet, city, tate, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applipnt own property in any other If yes, what wunty? What Taxing Distrid? Has this deduc[ion been requested on
county in Indiana? property for current yeaf? (] Yes 0 No
COUNTY AUDITOR
Deduction approved in the amounl of:
zo D.3 zo Q/� zo �,� Zo zo � Zo � Zo �
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Signature County Aud'Aor Date
I/ We certiry under the penalry of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
i reside of Indiana and owner of the aforementioned property on March 1, 20
� ure owners full name) Person authorized by duly exewted Power of Attomey
or by IC 6-1.1-12-.07
Ful esi ent addr ss of ap ipn ^ Addre of authorized person
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