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STATEMENT OF MORTGAGE OR CONTRACT INDI
FOR DEDUCTION FROM ASSESSED VALUATION
State Form a3709 (R5 / 4-03)
Prescribed by Department of Local Govemment Finance
Coun Township Year
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To beRfiled�ln�person or by mail with the CountyAuditor o/ the county where the propeRy is located. Q�� � 51 20�4
Filing Dates: 1J Real Property: Dunng the 12 months belore May 11 0l the year the deduction is to be effective. �
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 "and March 2 of the year the deduction is to be eNective.
See reverse side for addifional instructions and qualifications. ; �R � r! °'«'`"'`-,�--�
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Appticant (owner or contia bu er- see restrictions on reverse side)
Taxing Distrid Key number / legal description Record number �
����P'arfl p/ /�� _�DI ^�'� Page number 5a 3 7
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Assessed value of reat property as of Mortgage / ContraU indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, wrrent year owneR ❑ Yes ❑ No
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if no, what is his ! her exact share of interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is different lhan that ot applicant, indicate below: Is the property in queslion:
❑ Real PropENly ❑ Mobile Hane QC &1.1-�
��ne of moRgagee or conlract seller
Address of mortgagee or contrad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, slate, ZIP code)
Does applipnt own propeRy in any other If yes, what county? Whaf Taxing Distrid? Has this deduction been requested on
county in Indiana? property for current year?� Yes❑ No
COUNTY AUDITOR
Deduction approved in lhe amouni of:
20 O(, 20 20 �� 20 �� 20 20 20
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Signature County Auditor Date
� We certify under lhe penalty of perjury that the above and foregoing information is lrue and correct and that the applicants was / were
sident of Indiana and owner of lhe aforementioned property on March 1, 20
Si ur rs full na e) Person authorized by duly executed Power of Atlomey
. or by IC 6-1.1-12-.07
F ident address o ap i nt Address of aulhorized person
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