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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�• �«• .� Siate Fom a3709 (RS / 4-03) _ ' . ---
� PrescnDed by Department ot Lotal G6vemment Finance _ � "1
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INSTRUCTIONS: I�l�l WU-x-� ' ""�-�^-- }'-�S`�' ~�( ZFile4Mark
To be filed in person or 6y mail with the CountyAuditor of the county where t propeRy is localed. �
Filing Dates: 1) Real Property: Dunng the 12 months before May 11 0/ the ye the deduciion is to be eflechve. �� �
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is.to,be ef/ective.
See reverse srde for additional instructions and qualifications. _/V�. _.._ _ � J
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Applicant
Key numTier / legal
Rewrd number �
Page number
Assessed value of real property as of MoAgage / Contrect indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, wrrent year owner? ❑ Yes ❑ No
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If no, what is his / her exacl share of interest? I owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicanl, indicate below: Is the property in question:
of mortgagee or contraU seiler
Address of mortgagee or contract seller (number and
of assignee or other owner or holder of mortgage
city, �tate, ZIP
Address of assignee (number and sGeet, city, state, Z1P code)
Does applicant own property in any other If yes, what county? What Taxing Distnct?
county in Indiana?
COUNTY AUDITOR
Deduction approved in the amount of:
20 !,�✓i 20 />�
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Signature
20 �_ ( zo D 9
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County Auditor
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❑ Real Property ❑ Mobile Hane (IC 61.
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Has lhis deduction been requested on
property for current yea(1(] Yes ❑ No
zo
Date
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certify under the penalty of perjury thal the above and foregoing information is true and corred and that the applicants was / were
ient of Indiana and owner of the aforementioned property on March 1, 20
>ianature ( ners (ull name)
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ull resident address of applicant
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Person aulhorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person