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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Stale Fortn a3709 (R4 / 10.01) _ � . _
Prescribcd by Department ol Local Govemment Finance
Count Township Year
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_11 � �J �L�/ �
INSTRUCTIONS: File Mark
To 6e filed in person or 6y mail wilh the County Audifor ol the county where the property is located. �"�AY � 9 2�03
Filing Dates: 1) Real Property: Dunng the 12 months 6elore May 11 07 the year the deduction is to 6e eNective.
2) Mobile Homes assessed under IC 6-1.1-7: Behveen January 15 and March 31 0/ t e.yea� the deductlon is to 6e effecfive.
See reverse side for additional instructions and qualifications. -/��,�,
GI65DN `OUtITY aUDiTOP
Appucant (owner or contract buyer- see restrictions on reverse side)
(�e�vin a e. 1 ar�cl �n M. �`{icl�e
Taxing Dislrid Key number / legal description
'(�n� ov, I wp . ' oo7-va�� g-oo
Assessed value of real property as of
March 1, wrrent year
Mortgage / Contract indebtedness unpaid as of
March 1, current year
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�rd number
003 �
: number
�53 '
Is the applicanf the soie legal or equitable
owneR ❑ Yes ❑ No
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 ihat of applicant, indicate below: Is the property in question:
❑ Real Properly O Mobile Home (IC 61.1-n
,�me of moAgagee or contrad seller �
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Address of mortgagee or contract seller (number and street, city, sfate, ZIP ' Q' �
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Name of assignee or other owner or hoider of mortgage
Address of assignee (numberand street, ciry, state, ZIP code)
Does applicant own property in any other I If yes, what county? I VYhat Taxing Distrid? Has this dedudion been requested on
county in tndiana? property for arzent year? � Yes ❑ No
)eduction approved in the amount of:
20 �,� 20 20
P.�,� ��,A � �
COUNTY AUDITOR
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County Auditor
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Date
/ We certify under the penalty of perjury that the above and foregoing infortnation is true and wrred and lhat the applicants was / were
� residenl of Indiana and owner of the aforementioned property on March 1, 20
Full resident address of applicant
R.R , a, Box I b A, Fort
4�l�Hg
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07 '�
of authorized person