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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn a3709 (R5/ a-03) �
P2saiCM Dy Department ol Local Govemment Finance
INSTRUCTIONS:
Coun Township Year
File Mark
To be filed in person or 6y mail with the County Auditor o/ the county where the propeRy is locafed.
Filing Dates: 1 J Real Property: Dunng the 12 months be%re May 17 0/ the year the deduction is to be�eifectl�e.� ��� `
2) Mobile Homes assessed under IC 6-t 1-7: Between January 15 and March 2 0/ the yeqcfhe ded`uction is to be�eff�ctive.
See reverse side for additional instructions and quali�cations. �L �` �_� ^
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Applicant o er or contract buyer - see restnctions op reverse side) �
��c G�✓E „� ,.� n�in�TOR
Taxin District ^ v ���' '
9 Key number / legal description Record�numlie O�
S'�% . O/3�0��'�� O U pagenumber �
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Assessed value of real property as of MoAgage / ContraU indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year 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 wilh whom. `
If name on record is different lhan that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-�
�Name of mortgagee or cor�ra�l� �C /� ���` /' /J ,�
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Address of 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 street, city, state, ZIP code)
Does applicant own property in any other If yes, what counry? What Taxing Disfrict? Has this deduction been requested on
county in Indiana? property for current year?Q Yes❑ No
COUNTY AUDITOR J
Deduction approved in lhe amount of:
20 20 � 20 0 20 � 20 � 20 20
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Signature County Auditor Date
I/ We certity under t penal of perjury that the above and foregoing information is true and corred and that the applicants was / were
�esident of India and ow r of the aforementioned property on March 1, 20
ISignature (owne s full na Person authorized by duly executed Power of Attomey
� �_� A/�G` or by IC 6-t.t-12-.07
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II reside address of pplicant Address of authorized person
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