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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn a3709 (RS / 6-03) ,
PrescnEeC �y Department of Local Govemment Finance
Coun Township Year
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INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor o) the county where the property is located. D E � 9 2?QQ3
Filing Dates: 1) Real Property: During the 12 months be(ore May i 1 0l the year the deduction is to 6e eflecfive.
2J Mobile Nomes assessed under IC 6-1.1-7: Between January 75 and March 2 0l the�year the deduction is to � eflective.
See reverse side for additional insWCtions and qualifications. �`^"'" `�%%��-` �t'"" �� �
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Applicant (owner or contract buyer - see re'ctions on reverse side)
Taxing Distrid Key number / legal description Record n mber
3
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Assessed value oi real property as of Mortgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March t, wrtent year March 1, current year ownef? �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 ihan that of applicant, indicate below: Is the property in question:
� eal Property ❑ Mobile Home QC G1.1-�
�me of mortgagee or coNrad se r —
S � - -- -- -
Address of mortgagee or contrad seller (number and street, city, state, ZIP
Nameofassigneeorotherownerorholderofmortgage Dra�verNO•.•••••••/� .•'�D
Address of assignee (numberand street, city, state, ZIP code) Card ND• •
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Does applicant own property in any other If yes, what counry? What Taxins ...,,.,�..�: nas this dedudion been requested on
counry in Indiana? property for wrrent yeaf�Q Yes� No
COUNTY AUDITOR
Deducti n approved in the amount of:
20 20 20 � 20 �_ 20 d 20 20
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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
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature w ers full name Person authorized by duly executed Power of Attomey
�j �� or by IC 6-1.1-12-.07
Full r nt address o( applicant Address of authorized person
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