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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
� FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
°. w� ✓ Siate Form a3709 (RS / a-03) , �
P2scn�ed by Department ol Local Govemment Financa ,..� ��
�
MAY � 0 2��C�
INSTRUCTIONS: ile Mark
To be /iled in person or 6y mail with the County Auditor o/ the county where the property is located.
Filing Dates: 7) Real Property: Dunng the 72 montAS before May 11 0/ the year the deduction is to 6e etfec� .�f ,z
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0l the yoa. t6e �e�f�' is fo.be.eflective.
(9850 �PP� ��.,�.•,..: �.
See reverse side for additional instructions and qualifications.
a j�- � 3- �a �� oa �� � 9 L� �� �
Applicant�a}vner or contract �.,;-.�y- see ,e,incnons on reverse mue� � �
Taxing Distrid /% " / Key number! legal descriplion Record number Q� /
�.��� � �� - ��.s�� �
Page number / ��
Assessed value of real property as of Mortgage / ContraU indebtedness unpaid as of Is the applicant the sole legal or E
March t, wrrent year March 1, current year owneR ❑ Yes ❑ No
9/ ��
If no, what is his / her exacl share o( interesl? If owned with someone other lhan spouse, indicate with whom.
If name on record is different lhan that ot applicant, indicate
o( mortgagee or contrect selier
Address of mortgagee or contract seller (number and streef, cify,
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, stale, ZIP code) .
Does applicant own property in any other I If yes, what county? What
county in Indiana?
Deduction approved in the amounl
20
Signature
�
COUNTY AUDITOR
20 �� 20 Q� 20
P P
County Auditor
property in questian:
❑ Real Pmperty ❑
Drawer NO.Q...�l,...l •�?2-
�
CardNO. .....' ................
20
Date
20
6-1.
=sretl an
!es ❑ No
' We certify under the penalty of peryury that ihe above and foregoing information is true and wrrect and that the applicants was / were
resident o( Indiana and owner of the aforementioned propeRy on March 1, 20
name)
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
Full resident�address of appTicant / Address of authorized person
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