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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION
'� J State Fwm a3709 (RS / 4-03) '
a.
;� PrescnDed by Departmeni of loral Govemment Finance
INSTRUCTIONS:
To be �led in person or by mail with the County Auditor of the county where the property is located. ^pp � 9 2004
Filing Dates: 1) Real P�operty: During the 12 months before May 11 of the year the deduction is to be €Ifec'tive: �
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o(th year fhe deduction is to be e ective.
See reverse side for additional instructions and qualifications. ��t%�� `�-'�`-�--i
/l iiiRs�i`i �.�U�\ I V I�U�i I ��,
Applicant (owner or confract
District
on r�ve/se side)
Key number / legal
Record number O �
n/ J.� O/��OO/T� �T Page number ���
4t.(�Cq v (J
Asses ed value of real property as of Mortgage / Contract indebtedness unpaid as of is the applicant the sole legal or equitable
March 1, wrrent year March�current yeer owner% ❑ Yes ❑ No
I 1 J
If no, what is his I her exact share of interest? If owned with someone other than spouse. indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
of mortgagee or contrad seller
Address of mortgagee or contract seller (number and street, city. state. ZIP
Name of assignee or other owner or holder of :nortgage
Address of assignee (number and st2et, citz :;afe, ZIP code)
❑ Real Property ❑ Mobile Horne (IC 61.1-n
/ �IiC#%%!/ �C/-7v
i.-- -
Does appliwnt own property ir. any cther ! It yes, what couNv� �;<ing District? Has lhis deduction been requested on
county in Indiana? _. — ' /IL,� � property for current year? n Yes ❑ No
Drawer NO.• v';• •� �
, . . ..... �
Deductionapprovedinthe CardNO.••••""�:������
zo �O zo �i _ i zo �Z za �_� � zo o q zo zo _
Signalure
P I P ; P
Couniy Auditor
Date
/ We certify under the penalty of perjury ihat the above and feregoing infonnation is true and corred and that the applicants was / were
resident of Indiana and owner of the aforemen;ioned property on March �, 20
fufl name)
Person authorized by duly executed Power of A�torney
or by IC 6-1.1-12-.07
address of ap�i�fit }ip�,bs�-q��+r.�Adtlress of authorized person