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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S J State Fortn a3709 (RS / 4-03)
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� P2sui0ed Dy Department of Loral Govemment Finance
INSTRUCTIONS: � � (�File Mark � �j�
To be filed in person or by mail wifh ihe CountyAUditor of the county whe�e the property is located. .� �i.J ��...1�"
Filing Dates: 1) Real PropeRy: During the 12 montbs be%2 May 11 0/ the year the deduction is to be eHective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year fhe, deduction �Ipe effective.
oee reverse swe ror aomaona� �nsrrucnons ana quauncanons.
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Applicant (ownerorcontract buyer- ee resMc�tions n reverse s' e) �`//� """"" "'°
Taxing Disirid Key number / legal description Record number
l,//, /�� OQ / _ � / (.7 �� _ �v Page number � ��
A�c. � d
Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equilable
March 1, current year March 1, current year owneR ❑ Yes ❑ No
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Ii no, what is his / her exact share of interest? If owned with someone other than spouse, indicate wilh whom.
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If name on record is different than that of applicant, indicate below: Is the property in question:
O Real Property ❑ Mobile Hane pC 61.1-�
�ame of mortgagee or contrad seller
Address of mortgagee or contrad seller (number and street, city, state, ZIP '
Name of assignee or other owner or holder of mortgage
,
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduclion been requested on
county in Indiana? property for curtent year?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
� �
20 20 20 � 20 �� 20 �� 20 20
P P
Signature County Auditor Date
�'/ We certify under fhe penalty of perjury that the above and foregoing information is true and correcf and that the applicants was / were
� resident of Indiana and owner of the aforementioned property on March 1, 20 �
gn ture (ownefs lull name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full esident address of applicant Address of authorized person
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