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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION n T Year
�. �� I State Fwm a3709 (RS / 4-03)
�
Presaibe0 by Department of Loc�al Govemment Finance � A 1 g 2005
� RucnoNS: �,y/'�"1,'
To 6e filed in person or by mail with the County Auditor o/ the county where the property is located. �NCOUN7Y���R
Filing Dates: 1) Real Property: Dunng the 72 months be%re May 11 0l the year the deduction is to be �i�E.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 75 and March 2 0/ the year the deduction is to be eNective.
See reverse side for additional instrucfions and qualifications.
Applicant (owner orFOntracf 6uyer - see rictions on r erse side)
Taxing Disirid Key number / Iegai desuiption Record number
�/ ' 73
Od� ^ oQ��� � � Page number
Asse ed value of real property as of Mortgage / ContraG indebtedness unpaid as of Is the applicant th�e �s le legal or equitable
March 1, wrrent year March 1, current year owner? [�iles ❑ No
�
Ii no, what is his ! her exacl share of interesl? If owned wifh someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the p perty in question:
�Property ❑ Mobile Home QC 61.1-�
�me of moAgagee or contrad seller �j
Address of mortgagee or contract seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of moAgage
, , D
Address of assignee (num6er and st�eet, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for current year?� Yes� No
�'� �/� � 7— 5/_ �� COUNTY AUDITOR �Q �
Deduction approved in the amount of:
20 O� 20 � 20 �� 20 � 20 20 20
P P �
Signature County Auditor Date
�'� We certify under the penalty of perjury that the above and foregoing information is true and correcl and that ihe applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
Signat (owners full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full residen addres applicant 76 Address ot authorized person
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