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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
:�w� / State Porm a3709 (RS l a-03) � VUL�f tfV�l [���ii �
� Prescribed Dy Departmem of Loral Gtivemment Finance ����� Urt ���<i IUfY
Subject to tin acce tance f
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INSTRUCTIONS: � .�no� `—y„� �Fi�e Mark
To 6e filed in person or by mail with the County Auditor of the county � t�ie r�i�% y is locate�l��� / Audta
Filing Dates: 1) Real Property: During fhe 12 months before May 11 of the year the deduction is to be eR otive � �
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2J Mo6ile Homes assessed under IC 6-1.1-7: Between Jaaq�G}� �15 ��rch 2 0( the yeai the deduchon �s to tie e ef( c'tiV€.
See 2verse side for additional instructions and qualifications. ��� V_„ ,,, ���OR '-
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Applicant (owner or contract b er- se stri ions on reverse side)
Taxing Distrid K number / legal description Record number
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l�� /�� � �Q � —0�' Page number �
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Assessed value of real property as of Mortgage / ContraG indebtedness unpaid as of Is the applica sole legal or equitable
March 1, current year March 1, wrrent year owneR �Yes �❑ No
o��a°d
If no, what is his / her exact share of interest? If owned with s eone olher lhan spouse, indicate with whom.
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If name on record is different than that of applicant, indicate below: Is the pr erty in question:
eal Properiy ❑ Modle Home pC 61.1-�
'� e of mortgagee or contrad seller �
Address of mortgagee or contract seller (number and street, 'ty, state, ZIP _ �
Name of assignee or olher owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code) ���
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Does applicant own property in any other If yes, what county? _,.,,�uon been requested on
county in �ndiana? � property for current year? � Yes � No
y, COUNTY AUDITOR a
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Deduction approved in the amounl of:
20 O 20 � 20 �_ 20 ��i 20 20 20
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Signature -� County Auditor Date
We certify under the penalty of perjury that ihe above and foregoing information is true and corred and that the applicants was / were
sident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners full name) Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
Full resident address of applicant Address of authorized person