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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION
+ �� / State Fwm a3709 (R514-03) � �
�� PmscriCed by Department of Local Govemment Finance
INSTRUCTIONS:
Coun Township Year
File Mark
To be filed in person or by mail with the CountyAUditor of the county where the propeRy is focated. MAR 3 1 ZQQ6
Filing Dates: 1) Real Property: During lhe 12 months be%re May 11 0/ the year the deduction is to be effective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0l the yee�.thae�dedy�c °n is to be effective.
See reverse side for additional inshuctions and quali(cations. , f�'
418$ON/0 UNiY AUBIfi6W
Applicant owner confract buyer- see res ' tions on revers s e) .
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Taxing slrid Key number / legal descript' Rewrd number Q/
i.��� O/9- o�o�a-� 9 `'
Pa e number n
y
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant lhe sole legal or equitable
March t, current year March 1, wrrent y ar ownef? ❑ Yes ❑ No
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If nb, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is difterent than lhat of applicant, indicate below: Is the property in question:
— — — — - ❑ Real Property ❑ Mobile Home (IC 61.1-�
me of mortgagee or conVact seller �� _j �� �
Dra���er NO ..................
Address ot moRgagee or contrad seller (i
Card NO . ..................... � � �� �/�� -/91��
Name of assignee or other owner or hold� ' (/ '
Address of assignee (number and s12et, city, state, Z!P code)
Does applipnt own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for current year? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20,� 20 20 0�'_ 20 ' 20 20 20
P �
Signature Counry Auditor Dale
We certify under the penalty of perjury lhat the above and foregoing information is true and corred and that ihe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (vwners (ull name) Person authorized by duty executed Power of Attomey
" � or by IC 6-1.1-12-.07
Full resi nt address of applicant Address of authorized person
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