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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�+ ��� I S1at8 Fortn 03709 (RS / 4-03)
� PrescAbed by DepaRment of Laal Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months 6efore May 11 of the year the deduction is to
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0) the
See reverse side Ior additional instructions and qualifications.
Applicant (owner or
Taxing Distrid
see restnctiQns on
Assessed v�Jue of real property as of
March 1, current year
Ii no, what is his / her exacl share of interest?
on record is different than that oi
of mortgagee or contract seller
Key number / legal
v�vZ —l'JV�I
Mortgage / Contrad indebted
March 1, current year
So 0
If o^�n�
�Y
Address of mortgagee or contract seller (number
Name of assiqnee or olher owner or holder
of assignee (number and st�eet, city,
indicate below:
code)
Does appticant own property in any other If yes, what county?
county in Indiana?
20
Signature
approved in the amount of:
rz,i��.��
state, ZIP
File Maric
6e e�v
yea d u on is��ve.
� �J
7 O � Page number � `
�f
ss unpaid as of
� o%
AUDIiOR
4r9
Is the applicant the sole legal or equitable
owneR ❑ Yes ❑ No
someone other than spouse, indicate with whom.
What Taxing District?
COUNTY AUDITOR
2o Q,
�
County Auditor
zo ��
Is the property
O Rea� Proper
❑ Mobile Hame QC 61.
Has this deduction been requested on
property for current year? Q Yes ❑ No
zo � zo
P
Date
We certify under the penalty of perjury ihat the above and foregoing infortnalion is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
�e(ownerns full name)� / Person authorized by duly execuled Power of Attomey
�,..,. //�, _. ./ l�f„�/.�„� ,,,i, 6. or by IC 6-1.1-12-.07
Full resiFkff(address of appliqni / IAddress of authorized person
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