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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm a3709 (RS / 4-03)
Prescn0ed by Department of Loral Govemmem Pinance
Coun Township Year
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor of the county where the property is /ocated.
Filing Dates: 1) Real P�operty: During the 12 months before May 11 of the year the deduction is to �e �iv� ��
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0l the ar thg d uctio is•to e ctive.
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See reverse side �or additional instructions and qualifications.
OCT 2 u 2003
Applicant (owner or conhact uyer - se restrictions on reverse side)
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Taxing istrict Key number / legal description Record-ii�m4ier�uU� v nU i O�t i
�_ / / /, i ' OO�/� �/D�(� QO Pagenumber
U7r/ � ��� �� 6
Assessed value of real property of Mortgage / Contract indebtedness unpaid as of Is the applicant e sole I al r equitable
March 1, cunent year March 1, curre�ear owner? ❑ Yes ❑
7� ��
If no, what is his / her exact share oT interest? If owned with someone other than spouse, indicate with whom.
If name on record is diHerent than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC E1.7-7)
�ne of mortgagee or contract seller _/y/
/ ��i
c�
Address of mortgagee or contract seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, ciry, 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 lndiana? property for curcent year? � Yes � No
COUNTY AUDITOR
Deduc6on approved in the amount of:
20 20 20 � 20 _� 20 �� 20 Q� 20
P
Signature CounTy Auditor Date
�� We certify under the penalty of perjury that the above and foregoing infortnation is true and correct and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
SignaJare (� r's lull name) � Person authorized by duly executed Power of Attomey
�(Jl or by ic s-i.i-iz-.o�
Full resident address of applica Address of authorized person
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