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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
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I State Porm 437W (RS / a-03)
• P�esvibetl by DepaM1ment of Local Gtivemment Finance
INS7RUCr10NS:
To be /iled in person or by mail with the Counry Auditor ol the county where the property is located. ��, ��J �J 2004
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to be eHective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year theFded� �tion is b Hective.
See reverse side for additional instructions and qualifications. :�'-�-�-,-•-�� ;i �
� '� G�c;Snu ^t��.:v=y a.UDITOR
(owner or�6ntract buyer - see
Taxing Distrid
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Assessed value of real property as of
March 1, current year
2ver�e��) e
Key number / legal description � Record number
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Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owneR ❑ Yes ❑ No
If no, what is his / her exact share of interesl? —� If owned with someone other than spouse, indicate with whom.
If name on record is different than lhat of applicant, indicate below: Is the property in question:
O Real Propelly ❑ Mobile Hmie QC Cr1.1-�
e of mortgagee or contracl seller / r �
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Address of mortgagee or contrect seller (number and street, ity, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street, city, state, ZIP code)
Does applirant own property in any other I If yes, what county?
county in Indiana?
Deduclion approved
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Signature
Drawer NO....°.�...�.. y......
Card NO. ...... g`.��.�!0 .....
What Taxing Di:
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COUNTY AUDITOR
in fhe amount of:
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County Auditor
20
Date
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certify under the penalty of perjury that the above and foregoing information is true and corred and lhal the applicants was / were
lent of Indiana and owner of the aforemenlioned property on March 1, 20
ire (owners /ull name)��/ ^' - Person authorized by duly executed Power of Attorney
iiAn.Yl i�%. /YY.00....w�i1 � or by IC 6-1.1-12-.07 ��
resident address oT applicannt Address of authorized person
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