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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
� �� ! Stata Fortn a3709 (RS / 6-03)
P2saiCed by Department ot Local Govemment Finance
�TRUCTIONS:
oe �led in person or by mail wiih the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the
See reverse side lor additional inshuctions and qualifications.
or contrect 6uyer - see rest
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Assessed value of ree
March 1, curzent year
no,
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I property as of
exact share of interest?
on
Key number
Coun Township Year
�-. File Maric
be��effect e.� �j
year therBeduction is,to be�tive.
DEC 15 2003
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Page number
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Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or e
March 1, current year owner? �Yes ❑ No
yDvdo
If owned with someone other than spouse, indicate with whom.
If name on record is diRerent than that of applicant, indicate below:
Name of mortgagee or wntract seller � �/
3
�iress ot mortgagee or contracl seller (number and street, city, state, ZIP
Name of assignee or other owner or holder ot mortgage
Address of assignee (number and street, city, state, ZlP code)
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❑ Mobile Home (IC E1.1-7)
Drawer NO....%�.-. S, a 9 f
Does applicant ovm property in any oiher If yes, what county7 What Ta Card NO . ..................... sted on
county in Indiana? - es❑ No
�O� �� COUNTY AUDITOR
Deduction approved in the amount of
20 U 20 20 � 20 �� 20 �$_ 20 � 20
� yP � � P P
Counry Audiror
Date
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i I We certify under the penalty of perjury that the above and foregoing infortnation is true and correct and lhat the applicants was I were
a resident of Indiana and owner of the aforementioned property on March 1, 20
"�nature wnels full n/am�e) Person authorized by duly executed Power of Attomey
� .._..0 �fin .�D .S� orbylC6-1.1-12-.07
Full resi¢�nt address of applicant �Address of authorized person