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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
� � �r' Stete Fortn d3709 (R5/4-03)
. Prescribed by Departmem of Local Govemment Finance
INSTRUCTIONS: '� � � F_,il_e Mark g
To be filed in person or by mail with the County Auditor of the county where the property is located.'� i�'; �%
Filing Dates: 1J Real PropeRy: Dunng the 12 months before May 11 0/ (Ae year the deduction is to-be effect��
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the yea �hOe. dedu`tio��o be effective.
See reJerse�side Ior additronal instrucfions and qualificaiions.
V U 1
Taxing Distr' ' ' �
�,k�,�,�r
essed vatue oi real property as of
March t, wrrent year
If no, what is his ! her�exact share of ii
If name on
reverse sidE)
�
Key number / legal description � � F
O 13 �00� 0 -00 `
Mortgage / Contrect indebtedness unpaid as of
March 1, current year
70 0 O C`�
Ihan that of applicant, indicate below:
d number Q �
number 11 i i(">
Is the applipnt the sole legal or equitable
owne(? ❑ Yes ❑ No
Ii owned with someone other than spouse, indicate with whom.
moAgagee or contract seller � � ��
of mortgagee or contrad seller (number and sf�eef, city, state, ZIP
Name of assignee or olher owner or holder of mortgage
Address of assignee�(numberand st2ef, city, state, ZIP code)
Does applicant own property in any other I If yes, what county? What Taxing Distrid?
county in Indiana? �
Deduction approved in the amount of:
20 �� 20 �_ 20 �'L
� P �
SignaWre
COUNTY AUDITOR
20
County Auditor
20
Is
❑ Real Property ❑ Mobile Home QC 61.1-�
Has this deduction been requested on
property for wrrent year?� Yes� No
20
20
We certify under the penalry of perjury thal the above and foregoing information is true and corred and that ihe applicants was / were
resident of Indiana and owner of the a(orementioned property on March 1, 20
Signature
Person authorized by duly executed Power of Atlomey
or by IC 6-1.1-12-.07
�esi�nt address of ap�cant ' Address of authorized person
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