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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Sute Fwm a3709 (RS / 4-03)
PmscnDetl by Deparimem of Local Govemment Finance
INSTRUCTIONS:
To be filed in person or 6y mail with the County Auditor of the county where the property is located. (� � �.ti u 2004
Filing Dates: f) Real Property: During the 12 months 6efore May 11 of the year the deduction is to be elfectiJe" `
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is to 6e eflective,
See reverse side for additional instructions and qualifrcations. �� Jg��
� GigSON CQUtdTY :;UDITCR �
Applicant (owner orcontracf buyer- see restrictions on se side)
Taxing D" t id Key number / legal descripti Record number
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Page number
O — �Q -
Assessed value of real property as of Mortgage / Contracl indebtedness unpaid as of Is the applicant the sol legal or equitable
March t, current year March 1, current year owne(? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is diHerent than lhat of applicant, indicate below: Is the propeRy in question:
❑ Real Property � Mobile Home (IC Crt.t-�
�me of mortgagee or contracl seller � j�
Address of mortgagee or contrad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Drawer NO...°��........
Address of assignee (number and street, city, state, ZIP code) �� c� q
CardNO. ...........!.........
Does applicant own property in any other If yes, what counry? �'°"a1e� �a m been requested on
county in Indiana? 6'�1 -�t �nt year?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 � 20 �� 20 �� 20 � 20 20 20
Y � !
Signature County Auditor Date
� We certify under the penalty of perjury that the 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 (ull name) Person authorized by duly executed Power of Attomey
� or by IC 6-1.1-12-.07
Ful re ident address of applicant Address of authorized person