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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION C n Township Year
' �'+ w� � ♦ State Form a3709 (RS / 4-03) �
� Pmscribed by Department of Local Govemment Financa
SEN 2 6 2003
INSTRUCTIONS: //''�� File Mark
To 6e filed in person or by mail with the County Auditor of the county whe2 the property is located��/� �
Filing Dates: 1J Real Property: Dunng the 12 months before May 11 0/ the year the deduction is to ��,�„x� �
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of th �e�t ys�(8�� e tive.
See reverse side for additional instructions and quali�cafions.
Applicanl (r�erorcontract buyer-
Tauing Disirid
�(�l�..!_(I/.�IX
value of real property �6 of
March 1, currenf year
If no, what is his / her exacl share of interest?
on reverse side)
yiffumber / legal description
(/
O/� - C����-dv
MoRgage / Contrad ir
March t, current year
��
as
Record number
Page number /���
n
Is the applicant the sole legal or equitable
ownefl ❑ Yes ❑ No
If owned with someone other than spouse, indicale with whom.
If name on record is different ihan that of applicant, indicate below:
;ame of mortgagee or contract seller Q/
Address of mortgagee or contraIX seller (nu ber and st2et, city, state, ZIP
or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? I Whal
county in Indiana?
Deduction approved in the amounf of:
� /_
Signature
20 � I 20 ��
�
s ihe property o
❑ Real Property
-o � , ��--
O �
l�-du..icl�,-4�, 1�1� � • (rr'4
�00 3 — � �-5 o Ass�-
M�l/)'i 0`
/�� �
COUNTY AUDITOR
20
County Auditor
20 �_ 20
P
Home (IC 61.1
?
% ��_
Dale
20
iescea on
Yes� No
We certify under the penalty of perjury that the above and foregoing informalion 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
authorized person