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`�'�°, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
= FOR DEDUCTION FROM ASSESSED VALUATION
'� y State Form a3709 (R3 / 10-DO)
� � P25cribed by SWte Boartl of Tax Cortuniuioners
Instructions for filing:
To be filed in person or by mail with the County Auditor of the county where lhe property is
lorated durina the 12 months before Mav 11 of the vear the deduction is to be effective. See
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NOV 13 2001
reverse side for additional instructions and qualifications.
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Applicant (owner or contract buyer - see restrictions on ve side)
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Taxing District Key number / legal descri on Record number
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Page number
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable,
March 1, curtent year March 1, current year ��j y� 0 Il owner? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
N= of moAgagee or contrad seller
Address f mortgagee or contrad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP code)
Does applicant own real property in any I( yes, what county? VJhat Taxing District? Has this deduction been requested on
other county in Indiana? property for current year? ❑ Yes � No
COUNTY AUDITOR
Deduction approved in the amount of:
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Sign ure County Auditor Date
I� We certify under the penalty of peryury that the above and foregoing information is true and correct and that the applicants was / were
�•ident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners full name) Person authorized by duly executed Power of Attomey
��!1 or by IC 6-1.1-12-.07
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Fu I resident address of applicant Address of authorized person
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