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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Siate Form a3709 (RS I 4-03)
Preun�etl Dy Depanment of Local Govemment Finance
: ,_ ti INSTRUCTIONS: � � � F;I��
To be filed in person or by mail with the CounryAuditor of the counry where the property is located. ��
Filing Dates: 1J Real Property: During the 12 months betore May 11 0l the year the deduciion is to be eHective. (�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 oflhe year the�q�c�lo� i��O�be eNective.
See reverse side for additional instructions and qualifications.
_ � 30 � � .5 c�b �°a'���
Applicant (owne or co c'� u er- see restriction o e e side) D�ggON
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Taxing District Key number / legal descripiion Record number �/'
�y
( �X ^� ^ �OO �S' � Page number �
L.i�J \ �J
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applipnt the sole legal or equite
March i, current year March 1, current year owneR ❑ Yes ❑ No
ao��
If no, what is his / her exad share of interest? If owned with someone other than spouse, indicale with whom.
If name on record is different Ihan that of applicant, indicate below: Is the property in question:
❑ Real PropeAy ❑ Mobile Home QC Cr1.
' me of mortgagee or contract seller
Address of mortgagee or contracl seller (number and street, city, te, ZIP
Name ot assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any olher If yes, what county? What Taxing Distrid? Has this deduction been requested c
county in Indiana? property for current year?[� Yes❑ I
COUNTY AUDITOR
Deduction approved in the amount of:
20 � 20 � 20 20 20 20 20
� P �
Signature County Auditor Date
/ We ceAify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resi nt of Indiana and owner of the aforementioned property o� March 1, 20
i ture (own Is full n�e� Person authorized by duly executed Power of Attorney
j� or by � c s-� . �-� z-.o�
Fu sident dress of applicant Address of authorized person . �
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