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` STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
: / State Fwm d3709 (RS / 4-03) -
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� PrescnDetl by Department of Local Guvemment Finance
INSTRUCTIONS: File Mark
To be filed in person or 6y mail with the CountyAuditor of the county whe�e the property is located. �� l� �'t '—�
Filing Dates: 1) Real Property: During the 12 months belore May 11 0/ the year the deduction is to be eflective.�� ,t J'
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year�the deduct on'is t�� e� ti e.
See reverse side for additional instnictions and quali�cations.
JUL i o 2004
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Applicant (ownerorcontract 6uyer- see 2stnctions on reverse side) � ' �� -�// J/�/
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Taxing islrid Key nu er / le description Record number
` O Page number �
Assessed value of real property as of Mortgage / Conlrad indebtedness unpaid as of Is the applican tF he sole legal or equitable
March 1, current year March 1, current year owner? ���'es ❑ No
96 � �..,
If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
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If name on record is different lhan that of applicant, indicate below: Is the property in question:
eal PropeAy p Moale Hmie (IC Cr1.1-�
�e of mortgagee or contrad seller
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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 (numberand streef, city, state, ZIP code) ' ��_ �r� ��
Drawer NO ...................
Does applicant own property in any other If yes, what county? �n requested on
county in Indiana? Card NO. . ��. � ve50 N°
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COUNTY nuui i VK
Deduction approved in the amounf of:
20 20 �� 20 20 O 20 20 20
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Signalure County Auditor Date
� We certity under the penalty of perjury that the above and foregoing information is true and correcl and that lhe applicants was / were
:sident of Indiana and owner of the aforementioned propeRy on March 1, 20
Signature wners Iul� me) Person authorized by duty executed Power of Attomey
or by IC 6-1.1-12-.07
Full resid nt a ss of applicanl Address of authorized person
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