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/ate=.c\ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS I County j Township I Year
a FOR DEDUCTION FROM ASSESSED VALUATION 1
State Form d yDe (R11/t-03) II��
%� Prescribed by Department of Local Government Finance
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INSTRUCTIONS: I,� `�
To be bled in person or by mail. JHIV f�e411614
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. IV u4 Y
Must be filed with the County Auditor or County Recorder of the county where the property is located County Auditor
on or before January 5 of the immediately succeeding calendar year. ❑ Co t R. rder
2)Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the
county where the property is located during the twelve(12)months before March 31 of each yeg(e'SON CO
deduction is sought. UNTY AUDITOR
See reverse side for additional instructions and qualifications.
IAool' n (o ner or contract uyer-see restrictions on reverse side)
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Taxing district Ke number/legal description h�5• 5(or 7r Qv/0,,/21/V Record number age number
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Assessed value of real property as of I Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year I March 1,current year date of application legal or equitable owner?
i51 ) 001Q ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other tnan spouse,indicate with whom
If name on record is different than that of applicant,indicate below Is the propery in question:Annually Assessed
Real Property ❑Annually Assessed
I Mobile Home(IC 6-1.1-7)
I Name o` gagee tract eller
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Address of m gagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city.state,and ZIP code)
Does applicant own property in any other If yes.what county? what Taxing District? Has this deduction been requested on property
county in Indiana? for current year?
❑ Yes No ❑ Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 I 20 20 20 20 20
Signe:•re of County Auditor I County Date(month,day.year)
I(We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Sigpalure(owner's tuff m_) _ Date(month,day.year)
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Full reside dress of applicant(numbers re20 city,state,
a IP code)
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Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day.year).
Address of authorized person (number and street.city,state,and ZIP code)