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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Sta2e Fwm a3709 (R5/ a-03)
PrescriDed by Department olloral Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the CountyAuditor of the county where the property is locatetl.
Filing Dates: 1) Real Property: During the 12 months be(ore May 11 of the year the deduction is to be effecti�T 3 1 Z�03
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 ot the year the deduction is /t)o be effective.
See reverse side (or additional instructions and qualifications. � /(.J� n�
Appticant (owner or
Taxing District
�
see rest ''ons on reverse si
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IKey number / lega
I ,�11 /1 �2 -
Assessed value of real property as of Mortgage / Contract ir
March 1, current year March 1, current year
V '
If no, what is his / her exact share of interest?
If name on record is different than that of applicant, indicate below:
of mortgagee or contract seller
Address of mortgagee or contract seller (number
Name of assignee 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 wunty?
county in Indiana?
Deduction approved in the amount
�1f%� ' i
Record number r/I\ �
lJ
' O,� I Page number
as of I Is the applicant the sole legal br equitable
owner? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
ZIP
VJhat Taxing District?
COUNTY AUDITOR
20 � 20 � 20 �
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County Auditor
Is the property in question:
❑ Real Prc�erty ❑ Mobile Home (IC S1.
Has this deduction been requested on
property for curtent year? ❑ Yes❑ No
20 �_ I 20
P
Date
We certify under the penalty of perjury that the above and foregoing infortnation is true and correct 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
>s of aPplicant • IAddress of authorized person
$dX 2$3A'�¢