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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S ,«. / State Fwm a3709 (RS / a-03) '.. : . . _ , .. " _ _� �� � i
� Presaibe0 by Departmeni ot Local Gdvemment Finance �7� J ��!j
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INSTRUCTIONS: APR 2 g ��a�
To be (iled in person or.by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: Dunng fhe 12 months be%re May 11 0/ the year the deduction is to 6e ef/ective. % /f �//�
2) Mobile Homes assessed under IC 6-1 J-7: Between January 15 and March 2 0/ the year the-deduc� n.is�to.Sbe.effective.
See reverse side for additional instructions and qualifications. G� cp,y CUUN � Y^����' ��' '
(owner
/ legal descnption � � Record number
Oa� �f� O I /—O Page number 1�/� (^
V �' � Q( /J
Assessed value oi real property as of MoAgage / Contrect indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, cunent year � March 1, wrren� ye2r � owneR ❑ Yes ❑ No
If no, what is his / her exact share of inlerest?
If name on record is different than that of applicanl, indicate betow:
'ame of moAgagee or contrad seller �
/�
Address of mortgagee or wNraU seller (number and street, city, s
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand street,,city. �;ate, ZIP code)
If owned with someone other than spouse, indicate with whom.
-ao- ba-�ro3-
Is the pi
❑ Real
p �,
Does applicant own property in any cther I If yes, whal counry % lNhat Taxing District?
county in Indiana? i
I
_ -- — — - COUNTY AUDITOR
Dec �/
Drawer NO.. �.�.J......
2o a� �
CardN .....................
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20
�ouniy Audilor
❑ Mobile Home (IC 61.1-�
Has this deduction been requested on
property for current year? �] Yes ❑ No
� �zo�'L zo_
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� Date
�
/ We certify under the penalty of perjury that the above and foregoin, infonnation is true and corred and that the applicants was / were
�. resident of Indiana and owner of ihe aforemer.tioned pwperty on March 1, 20
of
I 1 '� /..
Person authorized by duly executed Po�ver of Attomey
or by IC 6-1.1-12-.07
of authorized person