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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn a3709 (R5 / 4-03)
PresaiDed Ey Department of Local Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of fhe county where fhe property is located. � � � 1 � 2003
Filing Dates: 1) Real Property: Dunng the 12 months before May 11 0/ the year the deduction is to be effec�iJe.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o/f the year the deduction is-to be ef%ctive.
See 2verse side fir additional instructions and quali�cations. 'S����c..� �t��
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Applicant (owneror ont buyer- e r strid n on �everse side)
Ta�cing Dist ' Key number / legal description Rewrd number �
D/� �/Z l o���� Page number �$7ys
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Assess value of real property as of MoAgage ! Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March , current year March 1, current year ownef? ❑ Yes ❑ No
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If no, what is his / her exacl share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is differenl than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Hmie QC 61.1-�
�ame ot mortgagee or contraIX seller
53
Address of mortgagee or cbntrad seller (number and s eet, city, state, ZIP
Name of assignee or olher owner or holder of mortgage
Address of assignee (number and street, ciry, state, ZIP code)
Does applicant own property in any olher If yes, what county? What Taxing District? Has lhis deduclion been requested on
counry in Indiana? property for current yeaf? � Yes � No
COUNTY AUDITOR
Deduction approved in the amounl of:
20 20 20 _Q� 20 �1 20 �� 20 �� 20 �
� P P
ignaWre County Auditor Date
�'/ We certify under the penaify of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
ig a, r(owners II am ) Person authorized by duty executed Power of Attomey
or by IC 6-1.1-12-.07
II resident ad ress of applicant Address of authorized person
R o� 9f t I�V �6