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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
� FOR DEDUCTION FROM ASSESSED VALUATION C un Township Year
����� J State Fortn A3709 (RS I 4-03) � q h �1 ��
• Prescribed Dy Department of Laral Gdvemment Finance ��
�NSnzucnoNS: MAR 0 7 2007
File Mark
To be filed in person or 6y mail with the County Auditor ol the county where the property is located. �-�,
Filing Dates: i) Real Property: Dunng the 12 months be%re May 11 of the year the deduction is to be e/fective'�a� ��
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o/the ye��f���educ��o�is.to���r��ective.
See reverse side for additional insfructions and quali�cations.
Applicant (owneror
Distrid
buyer-
Assessed value of real property as of
March 1, current year
If no, what ishis / her exact share
If name on record is diftereni ihan that of
me of mortgagee or contraq seller
�everse
Key number / legal description Record number
�� -�3 -30- aoo-000.�-�t �-oa� �
D�- �oa y,��DO Page number /� �
�
Mortgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owner? ❑ Yes ❑ No
� 1.0 ? . .
If owned with someone other than spouse, indicate with whom.
�G-/.�- v-�o�-oaa�5�%��
znt, indicate below: Is the property in question:
of moRgagee or conlract seller (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numtierand street, city, state, ZlPcode)
Does applicant own property in any other If yes, what county?
county in Indiana?
Deduction approved in ihe amount of:
20 ___Q� 20 ��
�
Signature '
What Taxing District?
COUNTY AUDITOR
20 � 20
p � /�
County Auditor
20
❑ Real Property ❑ Mobile Home pC 61.1
-s�ao
Has this dedudion been requested on
property for current yeaR � Yes ❑ No
20
Date
20
ify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
of Indiana and owner of the aforementioned property on March 1, 20
resident aAdress o( a plicant �
�[ 8 3�. a� S D S �.►� n,.�,
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Address of authorized person