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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm a3709 (RS / 4-03)
� Presaibed by Depanment of Local Govemment Finance I — I I
INSTRUCTIONS: �'rJ F1 Ma y ?j1�
To be filed in person or by mail with the County Auditor of the county where the property is located. -+1 -1� ��1�
Filing Dates: 1) Real Property: During the 12 mon[hs 6efore May 11 01 the year the deduciion is to be effective. .
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year fhe de`duct o� n is �o��e�effective.
See reverse side /or additional instructions and quali(cations.
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�Applicanl (ownerorconjra yer� $ee restri i s pn,(everse sidel r N � /1 �, -"`"U�;*�� �
Taxing District
Assessed value of real property as of
March 1, curtent year
If no, what is his / her exact share of interest?
/ legal description
March 1, current year
Co �DO�4
If name on record is diHerent than that oi applicanl, indicate below:
'3me oi mortgagee or contract seller
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Address of mortgagee or contract seller (number and street, city, s
Name of assignee or other owner or holder of mortgage
of assignee (number and st2et, city, state, ZIP code)
Reco�umber ^�
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� Page number J /� �Q�
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ss unpaid as of Is lhe applicant the sole legal or equitable
owneR ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
ZIP
Is lhe property in queslion:
❑ Real PropeAy ❑ Mobile Hane (IC Cr1.1-n
Does applicant own property in any other I If yes, what county? I VJhat Taxing District? Has this deduction been requested on
county in Indiana? property for current yea(? 0 Yes❑ No
Dedudion approved in fhe amounf of:
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Signature
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COUNTY AUDITOR
20 �s 6 zo a� zo zo � zo
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County Auditor Date
/ We certify under the penalty of peryury that the above and foregoing information is true and correct and that the applicants was / were
resideni of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
of authorized person