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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
L�M� J Staro Fwm a3709 (RS / 4-03)
� �"�aiDea by Department of Local Govemment Finance
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Coun Township Year
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INSTRUCTIONS: File Ma
To 6e filed in person or by mail with the CountyAuditor ol the county where the property is located. F E B 1%��04
Filing Dates: 1J Real Property: During the 12 months belore May 11 0l the year the deduction is to be efrective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the yeai the dedyuction is.�o be effective!
See reverse side /or additional instructions and qual�cations. /�'�"�^ •l�J %�� L�/
�' G!BSON COU:7i � =.UDiTOR
Appiicant (o or contract b er - see restrictions on reverse side)
Taxing Distri Key n ber J legal description Record number ,y, �
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-� 0( q- a a 6��-oo Page number ��^
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Assessed value of real property as of MoAgage / Contred indebtedness unpaid as of Is the applipnt the sole legal or equitable
March 1, current year March 1, currenl year ownef? �?;;Yes ❑ No
3 3 aso .00
If no, what is his / her exad share of interest? If owned with someone other than spouse, indicale with whom.
If name on record is different than that of appiicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home pC 61.1-�
me of mortgagee or contract seller
- 5 E e- �4 TT•4 G(-{ �
Address of mortgagee or conVad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder oi mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applipnt own property in any other If yes, what county? What Taxing District? Has this dedudion been requested on
county in Indiana? property for wrrent yeaR� Yes� No
N�
COUNTY AUDITOR
Deduclion approved in the amount of:
20 n_f 20 20 � 20 20 Q� 20 20
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Signature County Auditor Date
We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
resident of Indiana and ow er of the aforementioned property on March 1, 20
Si na e o�ners full na e Person authorized by duty executed Power of Attomey
� � or by IC 6-1.1-12-.07
Fu sidenl plicant Address of authorized person
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