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44`,... STATEMENT - NESS County Township Year
4 .-4; FOR DEDUC1
�"1\��t . L State Form 43709(R1 Drawer NO [�Ib.5ptk <Tghn j
�'�•�l. Prescribed by Depl h
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`\i File Mark
INSTRUCTIONS: To be filed in Card NO. v Form filed with:
Filing Date: Form must be cc :sought.
Must be filed or Inty where the property is County Auditor
located on or before January 5 of the calendar year in which the property taxes are first due and payable. ❑ County Recorder
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
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Taxin District Key number/legal description Record number P ge number
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Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application V� legal or equitable owner?
de \�� 000- ❑Yes ❑No
If no,what is his/her exact share of interest? If owned with someone other titan spouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is th operty in question:Annually Assessed
P.?..-rty ['Annually Assessed
, Mobile Home(IC 6-1.1-7)
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Nark of mortg ntr seller
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Address of mortgagee or contract seller(number and street,city,state,and ZIP code) 12)
B ®r,,20
Name of assignee or other owner or holder of mortgage G / 2J
Address of assignee(number and street,city,state,and ZIP code) C0UQ
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Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,sra amount of deduction
other county on property for
in Indiana? ❑YeS ❑No current year? ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity line of credit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor aCounty Date
e((month,day,year)
1/W ertify under the penalty of perjury that the above and fo ego information is true and correct and that the applicant is a resident of Indiana and
owner/ ntract buyer of the aforementioned property on date application is filed.
Sign�ere(o ne's full name) Date(month,day,year)
Full real ent dress of applicant(number and strdcity,state,and ZIP code)
Person authorized by duly executed Power of Attorney or ay it 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,city,state,and ZIP code)
The nenalties fnr neriury ran inrlude imnricnnment fin to twn and a half years and a fine not to exceed. 10.000.