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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
� FOR DEDUCTION FROM ASSESSED VALUATION
: I State Form a3709 (RS / 4-03;
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PrescnDeO Dy Depanment of Local Govemment Finance
INSTRUCTIONSr
Coun T Year
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OCT 1 9 2005
File Mark
To be filed in person or by mail with the County Auditor of the county where the propeRy is located.
Filing Da(es: 1) Real Property: Dunng the 12 montbs before May 11 of the year the deduction is to be eRer1 vr e�� �
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o)the y���t�l�ehded�f(cpyi �pa(Bf(ective.
See reverse side for addifional instructions and qualifications.
Applican wner or ontract 6uyer - see rictio s on reverse side) . ,
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Tauing D rict Key number / legal description Record number
DO _ � _ � DO �_ �� _ \ Page number
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant ihe sole legal or equitable
March 1, current year March 1, current year owne�? �es ❑ No
�f no, evhat is his / her exact share of interest? 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:
eal Property ❑ Mobile Hm�e QC 61.1-�
�,me of moRgagee or contrad seller � �"/
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Address of mortgagee or contreIX seller (number and street, cify, state, ZIP
Name of assignee or other owner or holder of mortgage
F�ddress of assignee (num6er and street, city, state, ZIP code)
Does applicant own properfy in any other If yes, what county? What Taxing District? Has this deduclion been requesled on
county in Indiana? property for curtent year? � Yes � No
COUNTY AUDITOR
Deduction approved in the amouni of:
20 20 _Q� 20 �� 20 20 20 20
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Signature County Auditor Date
� We ceAify under the penalty of perjury that the above and foregoing information is true and correcl and that the applicants was / were
a resident of Indiana and owner of the aforementioned property on March 1, 20
Scignature (owners (ull name) Person authorized by duty executed Power of Attorney
or by IC 6-1.1-12-.07
Full resident address of appiicant Address of authorized person
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