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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Sfate Fortn a3709 (R4 / 10-01)
Presuibe0 by Depariment of Local Govemment Finance
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 located.
Filing Dates: 1) Real Property: During the 12 monfhs before May 11 of the year the deduction is to be eHective.
2) Mobile Homes assessed under IC 6-1.1-7: BeKveen January 15 and March 31 of the year t�duction is to be eHective.
See reverse side (or additional instn�ctions and qualifications.
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Applicanl
Taxing Distrid
side)
/ legal
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Asses�e(1 vatue of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March��� curtent year March 1, curtent year owneR ❑ Yes ❑ No
If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is dif(erent ihan thai of applicant, indicate below: Is the property in question:
of mortgagee or contrad seller
�/ �, ,
Address of moRgagee or conVact seller (number and street, aty, state, ZIP
assignee or olher owner or holder of mortgage
Address of assignee (num6er and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Disirid?
county in Indiana?
COUNTY AUDITOR
Deduction approved in the amouni of:
20 �
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Signature
Fr,i.r��
20 Q`�
P
County Auditor
20 O�
❑ Real Properiy ❑ Moble Home (IC 61.
Has this deduction been requested on
properiy for curtent year? � Yes � No
20 �� I 20
/ We certify under lhe penalty of perjury that the above and foregoing infortnation is lrue and corred and thal ihe applicants was / were
� resident of Indiana and owner of lhe aforementioned property on March 1, 20
Person authorized by duly executed Power oi Attomey
or by IC 6-1.1-12-.07
of authorized person