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"f' �;' FOR EDUCTIION FROM ASSESSED CONTRACT UATION INDEBTEDNESS County Township I Year
State Farm 43709(R71 I 6-09)
Prescibed by Department of Lod Government Finance N is t 118 r )
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INSTRUCTIONS: Form filed with:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located_t� ,1
Fling Dates: 1) Real Property:Must file during the year for which the deduction is sought. f to 11.° M$ 4 County Auditor
2) Mobile I Manufactured Homes not assessed as Real Property Must file during the twelve(12)months
before March 31 of each year the deduction is sought - ❑ County Recorder
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See reverse side •r additional ins ns and qualifications. . • vR N;
Appowm(owner -ii ...'uye s reverse see) (�IBSON COU1 IY AUDITOR
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value of real property as of Mortgage/Contra=indebtedness unpaid as of Mortgage I Conttac indebtedness unpaid as of Is the app5rant the sole
March 1,acres year March 1 =r t year date of app(�tion legal or equitable owner?
In CV, ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
It name on record is dfferent than that of applicant,indicate below is the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
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Motile Home(IC 6-1.1-7)Name of mortgagee cc contract seller
Address ofmortpacee or nvt,�,.r•va..r,...:.____�_._.. _ de)
Name lass yyv0(Q Drawer NO., e)
Address of a //�
Does apples Card N O. (G?/ What Taring District? for anem yeati been requested on property
county in Ind .
❑ Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of
20 20 20 20 20 20_ 20
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Sig\/. � •ito \/ j I ' County Date(month,day,year)
II 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.
Signature(owner's 1I name) Date(month,day,year)
0 resident address of appfimnt(number and sheet.aly,state,and ZIP code)
\\\777 ens n authorized by duly exewted Power of Attorney or by IC 611.1-12-0.7 Date(month,day year)
Address of authorized person (number and street,city,state,and ZIP code) .