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STATEAAENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
\ � � " J State Form e3709 (RS / 4-03) � � ��
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Prescribetl Dy Department of local Govemment finance
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INSTRUCTIONS: ' SEP `Z�e�aQ�
To be filed in person or by mail with the CountyAuditor ol the county where the property is located
Filing Dates: i) Real Property: During the 12 months before May 11 of the year the deduction is t ec '
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of �g�� ���1T0R ective.
See reverse side /or additional instructions and qualifrcations.
Applicant (o ner or contract buyer- see Mctions on rever side)
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Taxing islrid Key number / legal cri i Record number /� �
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As ssed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicanl the sole legal or equitable
March 1, current year March t, wrrent ear owner? ❑ Yes ❑ No
If no, whaf is his / her exacl share of interest? If owned with someone olher than spouse, indicale with whom.
If name on record is different ihan that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Modle Home QC 61 _1-�
3me of morigagee or contrad seller ��� _
Address of mortgagee or contrad seller (num er a O D
Drawer NO.G.1•7•••�•5:••�.�
Name of assignee or ofher owner or holder of moR� �
CardNO . .....................
Address of assignee (num6erand street, city, state_
Does applicant own property in any olher If yes, what county? What Taxing Districl? Has this deduction been requesled on
county in Indiana? propeAy for current year? �] Yes❑ No
COUNTY AUDITOR ,
Deduc6on approved in the amouni of:
20 20 20 �� 20 �Z 20 O� 20 � 20
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Signature County Auditor Date
�' I We certify under the penalty of perjury that the above and (oregoing information is lrue and correct and lhal the applicants was ! were
. resident of Indiana and owner of the aforementioned property on March 1, 20
Signalure (o ners lull name) Person authorized by duly executed Power of Attomey
�f% or by IC 6-1.1-12-.07 '
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uli resident address of applicant Address of authorized person
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