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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
� �w� ! Siate Form d3709 (R5 / a-03) ,
� Prescnbed by Department of Loral Govemment Finance
INSTRUCTIONS:
To be filed in person or 6y mail witA the CountyAuditor of the county whe�e Ihe propeRy is located. FEB � � Z��6
Filing Dates: 1) Real Property: Dunng the 12 montbs betore May 11 0/ the year the deduction is to 6e eflective.
2J Mo6ile Homes assessed under IC 6-7.7-7: Between January 15 and Ma�ch 2 0/ the ye e deduction is to be effective.
See reverse side for additional instructions and qualifications. �� 'e�
@I8�6N COUNfiV AUBIfi9p
or contract
Taxing
�
A essed value of real property as of
March 1, curcent year
side)
kCey numb�r / legal descriptioQ/ Record number
�'� Q���'� Pagenumber
Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owneR ❑ Yes-rl No
., _
i
If no, what is his / her exact share of inleresl?
I( name on record is differeni than that of applicant, indicate below:
of mortgagee or contrad seller
Address o( mortgagee or contrad seller
r 6-C�LJ I i "
owned with someone ot�- � ��
� �
�m er and s6eet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county?
wunty in Indiana?
20�1
1
Signature
approved in the amount of:
20 O �
/
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What Taxing District?
COUNTY AUDITOR
20 � 20 20
r
County Auditor
iom.
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Has this deduclion been requested on
propeAy for wrrent year? � Yes ❑ No
20
Date
20
We certify under the penalry of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power ot Attorney
or by IC 6-1.1-12-.07
muie�yo� appucam Address of authonzed person
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