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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Siate Fwm a3709 (R514-03)
PrespiDed by Department ot Local Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with (he County Audiror of the county where the property is located.
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Filing Dates: 1) Real Property: During the 12 months be%re May 11 o/the year the deduction is to be eKective. � 1 2��5
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction is to be eNective.
See reverse side for additional instructions and quali�cations. `�j��� � G
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Applicant (owneroi co ct yer - se resMcti s on e rse d) V V V v vV V vV v
Taxing Distrid Key n er / legal description Record number 0�
•� \ n /�D / /�_y��1 Pagenumber ��/� .
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Assessed�vatue of real property as of Mortgage ! Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year � March 1, current year owner? ❑ Yes ❑ No
( �./ (,/V
it no, what is his / her exad share of interest? If owned wi[h someone other than spouse, indicate with wnom.
If name on record is different than lhat of applicani, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home pC 61.7-�
�ime of mortgagee or contraIX seller
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Address of mortgagee or coniraIX selier (number and street, city, state. ZIP � O,
Name of assignee or other owner or holder of mortgage I I�' �
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Address o( assignee (number and street, city, state, ZIP code)
�Does applicant own�property in any other If yes, what counry? What Taxing Districl? Has this dedudion been requested on
county in Indiana? � property for current year? � Yes ❑ No
COUNTY AUDITOR
Deduc6on approved in the amounl of:
20 ��_ 20 � 20 �� 20 20 20 20
P
Signature Counry Auditor Date
�yWe certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
,3 resident of Indiana and o er of the atorementioned property on March 1, 20
Signature (owners full na ) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full re ide address of app i Address of authorized person
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