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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�+ w� �/ SUte Form a3709 (RS / a-03) '
� Presai�ed by Departmem of Laral GovemmeM Finance
Year
INSTRUCTIONS: � 1 � y� �
To be filed in person or by mail with the CountyAuditor ol the county where the propeRy is located. �1�
Filing Dates: 1) Real PropeRy: During the 12 months be/ore May 11 0l the year the deduction is to be effe�, _��4g�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0( the year the deducti e effective.
See reverse side fo� additional instructions and qualifications.
�� ��
Applicanl (owner
see restrictions on
Ta�qp�q'istrid � = !
w� �
Assessed vatue of real property as of
March 1, current year�
If no, what is his / her exact share of interest?
name on record is diHerent than that of
of mortgagee or contract seller
Address of mortgagee or contraIX seller
Key number / Iegai description � Record number O
p� �) .�
O / 7 � O�y9 Y,. � � Page number � ^ � � ,
/ l �% �i
Mortgage / Contract indebledness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owner? ❑ Yes ❑ No
0 �-� � � � �
Ii owned with someone other than spouse, indicate with whom.
indicale betow:
�' �
�d st�eet, city, sta , ZIP
Name of assignee or other owner or holder of mortgage
of assignee (numberand sfreet, city, state,
Dces appliwnt own property in any other I If yes, what county? I What Taxing District?
county in Indiana?
Deduction approved in the amount of:
20� 20_��_ 20�
� P
Signature
COUNTY AUDITOR
20
County Auditor
�
❑ Real Property ❑ Mobile Home (IC 61.1-�
Has this dedudion been requested on
propeAy for current yeaf?�] Yes� No
20
20
We certify under the penalty of perjury that the above and foregoing information is true and correct and that lhe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
�ure (owner's full name Person authorized by duly executed Power of Attomey
(� . �. \�,..,�� or by IC 6-1.1-12-.07 �
Full resident addrass o( appiic�nt ^ �� Address of authorized person
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