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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
` FOR DEDUCTION FROM ASSESSED VALUATIO� �� 7ownship Year
�`+ / State Form a3709 (R5l a-03) - �
N '
PrascnGed Ey Deperirtreni of Local Govemment Finance
� ,
� srRUCrioNS: APR 1 0
File Mark
To be filed in person or by mail with the CountyAuditor of the county where the prope is localed�
Filin Dates: 1 Real Pro eA : Durin the 12 months belore Ma 11 of the ear the d�� �"� '`v ��
, 9 1 P Y 9 y y �cLor �s fo be e(/ective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15�(7ar�;�jDfitlie�y�i�r��� deduction is to be eHective.
See reverse side /or additional instructions and qualifications.
Applicant
Ta�cing Distrid
��
Assessed value of real property as of
March 1; current year
If no, what is his / her exacl
on reverse side)
Key number / legal description
G�o^? -�/�/K - o
Record number
Page number / 5 a
MoAgage 1 Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owneR ❑ Yes ❑ No
79ood o�l -/3 �� 3cYi-C�(J/. �/d'-oGT
If name on rewrd is differeni than Ihat of appiicant,
Address of mortgagee or contract seller (number
Name of assignee or
owner or holder of mortgage
If owned wilh someone other than spouse, indicate with whom.
below:
city, state, ZIP
Address of assignee (numtier and sf2et, city, state, ZIP code)
Dces�applicant own property in any other If yes, what county? What Taxing Distrid?
county in Indiana?
I".� S� SUJ �� �a7-9 COUNTY AUDITOR
20
Signature
approved in the amount of:
20
�� I Zo P Z � I I
County Auditor
�
❑ Real
❑ Mobile Home (IC 61.1-�
Has this deduction been requested on
property for current year? � Yes ❑ No
zo
Date
2�
We certify under the penatty of perjury that the above and foregoing information is true and corred and that the applicants was / were
�esident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
resident address of applicant �Address of authorized person