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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNES�
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn a37o9 (Ra / 10-07)
PrescribeA by DeOartment ol Lotal Govemmeni Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county whe2 the property is
Fiiing Dates: 1) Real Property: During lhe 12 monfAs be(o2 May 11 of the year fhe deduction is to be �tiv�.7 �UU3
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and Ma�ch 31 0/ the year the dedu/c/tion is to be eNective.
See reverse side /or additional instructions and qualifica6ons. `/''�
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Applicant (o er or nt ct 6uyer - see res ' n rever ide)
Taxing Distrid Key number / legal description Record number �
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Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year ownef? ❑ Yes ❑ No
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If no, what is his / her exad share of interest? If owned wilh someone other than spouse, indicate with whom.
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If name on record is different than that of applicant, indicate below: Is the property in question:
O Real Properly ❑ Mobile Home QC &1.1-�
�.ame of moRgagee or coNrect seiler _ /
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Address of mortgagee or conVact seller (number and street, aty, state, ZI
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Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, sfate, ZIP code)
Dces applicant own property in any other If yes, what county? What Taxing District? Has this dedudion been requested on
county in Indiana? property for current yeaR 0 Yes ❑ No
COUNTY AUDITOR
Dedudion approved in the amount of:
20 20 20 20 � 20 �$. 20 l7 20
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Signature County Auditor Date
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./ We certify under the enalty of perjury that the above and foregoing information is lrue and correct and that ihe applicants was / were
a resident of Indiana and owner of the aforementioned property on March 1, 20
' nalure (owners /ull name) Person authorized by duly executed Power oi Attomey
or by IC 6-1.1-12-.07
ulI resident address of appliqnt Address of authorized person
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