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STATEMENT OF MORTGAGE OR CONTRACT INDEBTE�S�
FOR DEDUCTION FROM ASSESSED VALUATION ���
State Fwm a3709 (R4110-07)
Prescribed by Department of local Govemment Finance
15 2002
INSTRUCTIONS: �ggON C�OII �� ti' �UDITO�ile Mark
To be filed in person or by mail with the County Auditor ol the county where fhe property is Iocated.
Filing Dates: 1) Real Property: During the 12 months belo2 May 11 of the year the deduction is l0 6e effective. -
2) Mobile Homes assessed under IC 6-1.1-7: 8ehveen January 15 and March 31 0/ fhe year the deduction is to 6e effective.
See reverse side (or additional inst�uctions and qualificafions.
Applicant ( n or contract buyer- see restricti n reve e side)
Taxing Distrid Key number / legal description Record numpe� �
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Q� �I _ � Page number
Assess alue of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, rrenl year March 1, curtent year owne(? ❑ Yes ❑ No
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If no, what is his / her exacl share of interesl? 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:
❑ Real PropeAy ❑ Mobile Hmie pC 61.1-�
�e of mortgagee or contraIX seller J-r h� r
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Address of mortgagee or contrad selier (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does appticant own property in any other If yes, what county? What Taxing District? Has this deduc[ion been requested on
county in Indiana? property for wrrent yea(? � Yes ❑ No
COUNTYAUDITOR ',
Deduction approved in the amount of:
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Signature County Auditor Date
We certiy under the penalty of perjury that the above and foregoing information is true and corred and lhat ihe applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
igna re (owners lull name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Fu r si address of applicant Address of authorized person