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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNFcc
FOR DEDUCTION FROM ASSESSED VALUATION
State Form a3709 (R5 / 4-03)
Presai�etl Ey DepartmeM of Lorat Govemment Finaxe
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INSTRUCTIONS:
To 6e filed in person or by mail with the CounryAuditor o! the county where the property
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is� t�q eSectiGgO¢
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year lh�e deduction is to be eNective.
See reverse side for additional insfructions and qualiTcations. � � �'( �� �/
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�% G'BSvta COU>!l'� huvnvn .
Applicant (o ne� ntract buy r- restrictio verse side)
Taxing Distnct Key number / legal description Record number
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Assessed value of real property as of Mortgage / Contrect indebtedness unpaid as of Is the applipnt the sole legal or equitable
March 1, current year March 1�ent year n' b9$ owner? ❑ Yes ❑ No
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If no, what is his / her exacl share of interesl? It owned with someone other than spouse, indicate with whom.
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If name on record is different than that of applicanl, indicate below: Is the property in question:
O Real Property ❑ Mobile Hmie (IC G1.1-�
Name of mortgagee or contrad seller
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Address of mortgagee or contrad seller (number and stre , city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6erand sGeet, city, state. Ziemda�__ ___ _
Drawer NO �? 3— l° I 1�
Does applicant own property in any other If yes, � ���"""""' ' ias this deduction been requested on
county in Indiana? xoperty for wrrent yea(? O Yes � No
Card NO. .. .,,,,,,,,,,,
Dedudion approved in the amount of:
20 20 20 ' 20 � 20 �� 20 20
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Signature Counfy Auditor Date
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I/ We certify under the penalty of perjury that the above and foregoing infortnation is true and correct and that the applicants was / were
•resident of Indiana and owner of the aforementioned property on March 1, 20
aignature (owners (ull name) Person authorized by duly executed Power of Attomey
1 or by IC 6-7.1-12-.07 •
Full resident address of applicant ' Address of authorized person
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