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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION `� Coun 7ownship Year
� \• - _ �! State Fortn a3709 (RS / <-031 Q �
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PrescriEed Gy Department of Local Govemment Finance �
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INSTRUCTIONS: - � File Mark
To be filed in person or by mail with the County Auditor o! the county where the propeRy is located.
Filing Dates: 1) Real Property: Dunng the 12 months 6elore May 11 0l the year the deduction is to be e8ective.
2) Mobile Homes asseued under IC 6-7.1-7: Between January 15 and March 2 0l the year the deduction is to be eftective.
See reverse side for additional instructions and qualifications.
Applicant (owner r co rac er - see restri ' ns on rev e side) �
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Taxing Distrid Key number / legal description Record n r �� l �
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p� ' \ _� � � � Page number 3�a �
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Assessed value of r al property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owner? �1'es ❑ 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 different than that ot applicant, indicate below: Is the property in question:
� Real Property ❑ Mobile Hortie QC fr1.1-�
�me of mortgagee or�contra seiler � �
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Address of mortgagee or contrad seller (number and street, city, state, ZIP
Name of assignee or ofher owner or holder of mortgage
Address of assignee (numberand st2ef, city, state, ZIP code)
Does applicant own property in any other If yes, what counry? What Taxing District? Has this dedudion been requested on
wunty in Indiana? . property for wrrent year?� Yes❑ No
COUNTY AUDITOR
Deduction approvetl in the amount of:
20 20. 20 20 20 20 20
Signature � County Audifor Date
We certify under the penalty of perjury that lhe above and toregoing informalion is true and correct and that the applicants was / were
a resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners tull name) Person authorized by duly executed Power of Attomey
or by IC 6-7.1-12-:07
Full re�ident address of appli nt Address of authorized person
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