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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S�� J SUta Fortn d3709 (RS / 4-03)
� P2scdDed by Depanmeni ot local Govemment Finance �� �
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INSTRUCTIONS: QP�''�`'P004
To be filed in person or by mail with the County Auditor of the county whe2 the property is located.
Filing Oates: 1) Real Property: During the 12 months before May 11 01 the year fhe deduction is to be e chve.
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 oJ the yea he ded� is ! be eH ntiv
See reverse side /or additional instnictions and qualifications. � GI°_SON CGU�w� nUDtTOR
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Applicant (o nerorContract 6uyer- see sMctions on reverse side)
Tauing Distrid Key number / legal description Record number 0^
/ x � .�N j � Page number „�
L�U' \ C..JFJ 3,j
Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is lhe applipnt the sole legal or equitable
March t, wrrent year March 1, current year owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interesl? If owned with someone other than spouse, indicate with whom.
If name on record is different lhan that of applicant, indicate below: Is lhe property in question:
❑ Real Property ❑ Mobile Horrie pC 61.1-�
�ame of moAgagee or contrad seller ���
Address of mortgagee or contrad seller (number and streef, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, sfate, ZIP code)
Does applicant own property in any olher If yes, what county? What Taxing District? Has this deduclion been requested on
county in Indiana? property for current year? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in lhe amount of:
zo zo ; zo O 7 2o D g zo zo zo
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Signature County Auditor Date
�I / We ity under the penalty of perjury that the above and toregoing information is true and corred and that ihe applicants was ! were
a resi ent of Indiana and owner of the aforementioned property on March 1, 20
g t e(owners fuli name Person authorized by duly executed Power of Attomey
' or by IC 6-1.1-12-.07
Fu ident address of applicant Address of authorized person
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