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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNFec
FOR DEDUCTION FROM ASSESSED VALUATION
Staffi Fwm a3709 (R5 / 4-03)
PrescriDetl Dy Departmem of Local Gtivemment Finance
INSTRUCTIONS:
To 6e filed in person or by mail wiih the Counry Auditor o/ the counry where the property
Filing Dates: 1) Real Pioperty: During the 12 mon[hs 6efore May 11 0/ lhe year the deduction isIM be �(fe�tiP�05
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year lhe deduction is to be effective.
See reverse side for additional instructions and qualifications.
(owner
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Assessed value of real property as of
March t, currenl year
If no, what is his / her exad
interest?
on
Key number
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Record number /� �
(/
� � � —O� S,��Q� Page number � � �
MoAgage / Contract indebtedness unpaid as of Is the applicani the sole legal or equitable
March 1, current year owneR ❑ Yes ❑ No
I oZQ00'U
name on record is different Ihan that of applicant,
of mortgagee or conVact seller
Address of mortgagee or wnt�ad seller (number and st2et,
Name of assignee or other owner or holder of mortgage
below:
Address of as��^-- • ✓�
� K&iz �
,/z�Ks
Does applia , l M �
county in Ind. � � �� W � �
D5'�335 _
20
Signature
approved in the amounl of:
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If owned with someone other than spouse, indicate with wnom.
stafe, ZIP
What Taxing District?
COUNTY AUDITOR
20 �_ 20 20
PCounty Auditor
property in question:
❑ Real Property ❑ Mobile Hane QC 61.1-�
Has this dedudion been requested on
propertyforcunentyear?� Yes❑ No
20
Date
20
�1 We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
a resident of Indiana and owner of the aforementioned prq�rty on March 1, 20
Person authorized by duty executed Power of Atlomey
or by IC 6-1.1-12-.07
Full re\s�td.,ent addre1�'s1 o/f� �I�,p�lica1nt � - 1-_�"� Address of aulhorized person
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