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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Stata Fwm d3709 (R5 / 4-03) �
Prescri�ed by Department ol Local Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the counry where the property is located. � �� N� 5 2004
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to be eftective:
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ tbe year the deduction is to be eNective.
See reverse side for additional instructions and quali�cations. J
�� GI°SON COUtfT't �.UC�ITO�
Applicant (q�ynepo�contract buyer- see
Ta�cing
Assessed value of real properiy as of
March 1, cunent year
If no, what is his / her exad share of
on revers� side)
Key number / legal descriplion Record number �
�� M.�j� _ (f (� Page number ,?`J�� /
C�iC/ 01 � �O
MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal o� equitable
March 1, current ye2r ownef? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
If name on record is different lhan thal of ap�licant, indicate below:
iame of mortgagee or contrad seller ,/�� C�
r % %
Address of mortgagee contract selier (number and st2et, city, stati
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what wunty^ I\•Vhat —
county in Indiana?
Deduction approved in the amount of:
20 Q_� 20
�
Signature .
COUNiY AUDIT
❑ Real Property ❑ Mo6ile Home QC 61.1-�
QA
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oo-3va� . : . � �•
'� (r 20 � r.� 20 ��' 20 � 20
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County Auditor Da1
,�.2
Zi7
auested on
) Yes� No
' We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforemeniioned property on March 1, 20
lull name)
Person authorized by duly executed Power oi Attomey
or by IC 6-1.1-12-.07
Address ofauthorized person