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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
State Fwm a3709 (RS / 4-03�
«• -
—� P2saibetl by Depariment of Local Govemment Finance
�
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county whe2 the property is located. �� -''e �� �
Filing Dates: 1) Real Property: During the 12 months be%re May 11 0l the year the deduction is to be ecti
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 75 and March 2 0l the year the deduction is to be eflective.
See �everse side for additional instructions and qualifications. N � � 1 � Z�04
(owne� or
Distrid
?kssEssed value of real property as
March 1, curcent year
If no, what is his / her exact share
see
Key number / Tegal description
number
/(1 �l/\ j�� ^� p Page number ��/�
U `��� �liJfO y
Mortgage / Contred indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year ownef? ❑ Yes ❑ No
��T�/ �/ _ / ��
If name on record is different than Ihat of appiicant,
of mortgagee or contract seller
of morigagee or contract seller (number and
of assignee or
owner or holder of mortgage
Ii
city, state,
assignee (num6er and stieet, city, state, ZIP code)
ad with someone oth than spouse, indicale with whom.
�/a? -4/- �- DOU. �j/`9-C��
Is the property in questian:
Does applicant own property in any other I If yes, what county? What Taxing District?
county in Indiana?
Deduction approved in the amount of:
20
Signature
COUNTY AUDITOR
20 20 Q� 20 �
P P � �.�
County Auditor
Home pC Cr1.1-7J
�
Has this deduction been requested on
property for current year?�] Yes� No
20
Date
20
certiry under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
lent of Indiana and owner of the aforemenlioned property on March 1, 20
(owners full name)
�/t.�� C�i
nt address of applicant "
�;,�� // 4 � �
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07 ' �
Address of authorized person