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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
. «• / State Porm a3709 (RS / 4-03j .
� Prescribed by Deparimeni ot local Govemment Finance _ '
INSTRUCTIONS: �N �yy �a�
To be filed in person or by mail with fhe County Auditor of the county wbere the property is locate�d. .�
Filing Dates: 1) Real Property: Dunng the 12 months before May 11 of the year the deduction is to be effech�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of tf��e� tpe d�d�(ction is to 6e effective.
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See reverse side for additional instructions and qualifications.
(owner or contract buyer
Taxing Distrid
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�rev�rse
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/ legal descriplion � Record
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%1/`�� O/� � ! - O �• Page number � � D
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Assessed value of reai roperty as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equital
March 1, curreM year March 1, current year owneR 0 Yes ❑ No
, � �`000
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 than that of applicanl, indicate below: Is the property in queslion:
❑ Real Property ❑ Mobiie Home (IC 61.1
mortgagee or contraa seller
Address of moAgagee or wnlraq seller (number and street, city, state, ZIP �
Name of assignee or other owner or holder of mortc p20 a� _ /) /���
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Address of assignee (number and street, cify, state
Does applicant own property in any other If yes, w; ' / CC.. � this deduction been requested on
county in Indiana? �erty for current year? � Yes� No
Deduction approved in fhe amouni ot:
20_f�
Signature
20 _Q/
COUNTY AUDITOR
20 D °I 20 20
�
County Auditor
20
Date
20
We certify under the penalty of per�ury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
(r}��fu�rP'�(owners (ull name) Person authorized by duly executed Power of Attorney
N�lnrf� ��. � rilnn �n/Tvt S�'-I _ or by IC 6-1.1-12-.07
=ull resident address of applicant �J Address of authorized person
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