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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES
FOR DEDUCTION FROM ASSESSED VALUATION C n wn ip Year
�. - � J � State Fomi a3709 (R5/41131 ' /y)�
. Pr¢spipe.y Dy Departmem ol Local Govemment Finance O� T O� oo `� n
• I V
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INSTRUCTIONS: �fa� � File Mark
. To be filed in person or by mail with the County Auditor of the county where the property is 1,Qc�ated. �/ �
Filing Dates: 7) Real PropeRy: During the 12 months be%re May 11 0l the year the deductib}I�SS��@�'�TitfeAUDITOR
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction is to be eHective.
See reverse side for additional instrucfions and qualifications.
Applicant (o� r or cont2ct buyer - see resf �c6ons on reverse side)
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Tauing Districl / Key number / legal description Record number O�
l !!, �� e 1-,lY , �. , i%�, � � _ �I� �3 _� Page number
7CJ JC,f � i�.� v--�l�— ��
Assessed value ot real property as of MoAgage / ContraG indebtedness unpaid as of Is the appliwnt the sole legal or equitable
March 1, current year March 1, current year owner? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? i owned with someone other than spouse, indicate with whom.
- - 00 - UO . �5�3 - �JO
If name on record is different than that ot applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-�
�3me of mortgagee or contred seller � - . . �
/
Address of mortgagee or coniract selier (number end streeC city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any olher If yes, what u �� �7-��"� � � U m� s deduction been requested on
counry in Indiana?. �1� y for current year?� YesO No
�� O 5,
Deduction approved in lhe amount of:
20 20 �_ 20 b 9_ 20 20 20 20
P P
Signature County Auditor Date
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�� We certiy un er the penalry of perjury that the above and foregoing information is true and corred and lhal the applicants was / were
a r ident of In a and owner of the aforementioned property on March 1, 20
( Signat. e- ful na Person authorized by duly executed Power ot Attorney
� � � or by IC 6-1.1-12-.07
11 r nt of p i' t Address of authorized person