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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
= FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�+ �� � ! State Fortn a3709 (RS / a-03)
PrescriDetl by Depertmeni o( Loral Govemment Finance - •
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�TRUCTIONS: File Mark
� De filed in person or 6y mail with the County Auditor of the county where the property is located. � E � 1 � 2003
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is to be eilective.
2) Mobile Homes assessed under IC 6-1.1-7: Befween January 15 and March 2 0( the year fhe deduction is to 6e eBective.
See reverse side for additional instructions and quali�cations. f�> ct,_-. �%i .%'.`�- �-� ���
'� Gl3S(Y� (.''):. 'T � A1;71TOR I
or c�ntract 6uyer - see
Assessed value of real property as of
March 1, wrrent year
If no, what is his / her exact share of interest?
If name on
than lhat of
moRgagee or contract seller
Key number / legal description I Record number
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O / �_ � � � � / _ � Page number
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Mortgage / Contract indebtedness unpaid as of Is the applicant t e ole legal or
March 1, current year owner? es ❑ No
If owned with someone other than spouse, indicate with whom.
of mortgagee or contract seller (number aqd�treet, city, state,
or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZlP code)
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Does applicant own prope in any ther If yes, what county?
county in Indiana?
Deduction ap�roved in the amount
20 20
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Signature
Is
❑ Mobile Home (IC 61.
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What Te � �OR3 ' �'�d2' �!�/O-) ] No
COUNTY AUDITOR
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County Auditor
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20 �_ 20
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Date
I/ We certify under the penalty of perjury that the above and foregoing infortnation is Irue and correct and that the applicants was / were
a resident of Indiana and owner of the aforementioned property on March 1, 20
(ull name)
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Person aulhorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
aulhorized person