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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
� FOR DEDUCTION FROM ASSESSED VALUATION
� �� � Slate FOrm a3709 (R4 / 76-01) '
PrescribeA by Deparimenl ot Loal Govemment Finance
1 �- ,�
INSTRUCTIONS: �Fil� ATa.rk�
To be filed in person or by mail with the County Auditor oJ the county where the propeRy is located. 't—� �L��
Filing Dates: 1) Real Property: During the 12 months befo2 May 11 o/the year the deduction is to be ef�at��.� �^�
2) Mo6ile Homes assessed underlC 6-1.1-7: Between January 15 and March 31 0l the year fll deducti �� o be eHective.
See 2verse side lor adddional instructlons and qualifrcations.
Girt n n� J���" _ _`t-'_�(
Appiicant (owner pf buyer - se sM ' ns on reverse side) "� '' '
Taxing Distrid Key num / legal description Record number __
� f „� „ I n� O�� - Page number ���
\,t��. ♦ ..'
Assessed value of real property as of MoAgage / Contract indebtedness unpaid as of Is lhe appliqnt the sole legal or equitable
March i, wrrent year March 1, cunent year owneR ❑ Yes ❑ No
If no, what is his / her exact share of interest?
If name on
ihan ihat of applicant, indicate below:
mortgagee or contrad seller
If owned with someone other lhan spouse, indicate with whom.
Address of mortgagee or contred selier (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee
Dces applicant own property in any
munty in indiana?
Deduction approved in the amount of:
20 �
Signature
state, ZIP code)
Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-�
If yes, what counry? Nfiat Taxing District? Has this dedudion been requested on
property for curtent yeaR � Yes ❑ No
COUNTY AUDITOR
� . � � ; ��'/L��
County
I.
20 ��
�
Date
20 O �
We certify under the penalty of perjury lhat the above and foregoing infortnation is true and corred and that ihe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
�nature (owners (ull name) Person authorized by duly executed Power of Attomey
�. % f._. i7o or by IC 6-7.1-12-.07
FuII resYdent addr�ssq� ppli nt �1 Address of authorized person
I��l 1 4� .� t�"i-r�� 7�?C�