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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
�' s FOR DEDUCTION FROM ASSESSED VALUATION
♦ � Slale Form a3709 (R4 / 10-0t )
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PresaibeA by DeDaNrent W Loral Govemment Finance
Year
INSTRUCTIONS: {r' � jJ � � Mark
To be filed in person or by mail with the County Auditor of the county where the property is�ocated. U�02
Filing Dates: 1) Real Property: During the 12 months belore May 11 oJ the year the deduction is� el�eCt'
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 31 o the year th�educli is be e/lective.
See reverse side lor additional ins6uctions and quafifica6ons. � ,� /,
Applicant
�
Assessed value of real properly as of
March 1, current year
restrictions
r
no, what is his / her exact share of interest?
If name on record is different than that
mortgagee or contraU seller
Key number / legal description
/� - �-�� Page number � � �
MoRgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or e
March 1, current year ownef? ❑ Yes ❑ No
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If owned with someone other than spouse, indicate with whom.
Address of mortgagee or contracl seller (number and
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street,
Dces applicant own property in any
counry in Indiana?
Deduc[ion approved in the amount of:
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Pr�v �+- I �
Signature
C(Iy,
If yes, what counry? � What Taxing Distrid?
COUNTY AUDITOR
20 20� 20
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County Auditor
❑ Real Property O Mobile Hane OC E1.
Has this dedudion been requesled on
property for curtent year? 0 Yes ❑ No
�
Date
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We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
��n�at�(e(owners Iull ame) Person authorized by duly exewted Power of Attomey
�( ��j ��M� �� �— or by IC 6-1.1-12-.07
ivt,u� i � w�`
I reside�ress o applipnt Address of authorized person