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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
= FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�+ ♦ Sfate Fortn a3709 (RS / a-03)
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� PresaiCed by Dapenment of Local Govemment Finance
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INSTRUCTIONS: �File Mark �
To be filed in person or by mail with the County Auditor of the county whe2 the property is Ix e �� c� �
Filing Dates: 1) Real Property: During the 12 months be)ore May 11 of the year the deduction i o be
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Ma�ch 2 o e year t e eduel� js to be etfective.
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Applicant r or contract �buyef - see res ' tions on reverse ide) /u C1a��,j�`t�,1 Y�,�Di��^ '
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Taxing Distrid Key numb / legal description Record number
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, cunent year March 1, current year owner? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
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If name on record is different than that of applicant, indicate below: the p erty in question:
❑ Real Properry ❑ Mob�le Home pC E1.1-7)
'-�ne of mortgagee or contract seller // �
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Address of mortgagee or contract seller (number and street, city, sta , ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sireet, ciry, state, Z/P code)
Does applicant own property in any other If yes, what county7 What Taxing District? Has this deduction been requested on
counry in Indiana? property for curtent year? ❑ Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amouni of:
20 2o zo zo � zo a 20 0 Y 20 6 9
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Signature n I � County Auditor Date
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I! We certify under the penalty of perjury that the above and foregoing information is true and correct and that Ihe applicants was / were
��si nt of Indiana and owner of the aforementioned property on March 1, 20 .
Sign ur (owners t name) Person aulhorized by duly executed Power of Attomey
� or by IC 6-1.1-12-.07
I esident addre of applicant y,,��a Address of authorized person
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