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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn C3709 (RS / 4-03)
Prescribed Gy Depanment of Local Gtivemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located. �F p 1 9 Z003
Filing Dates: 1J Real Property: During fhe 12 months before May 11 0/ the year the deduction is fo be efl hck
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of tAe r the deductio to be effe ive.
See reverse side for additional instructions and qualifications.
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Applicant nerorcontract 6uyer- e restrictions on r rse side)
Ta�cing Distrid Key number / legal description Record number O�
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Assessed value of real property as of Mortgage / Contracl indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrrent year March 1, current year ownef? ❑ Yes ❑ No
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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 different than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home QC 61.1-�
�me of mortgagee or contract seller
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Address of mortgagee or contracl seller (number and st2et, city, state, IP
Name of assignee or other owner or holder of mortgage -- --
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Address of assignee (num6erand stieet, city, state, ZIP code) DI'BWQC lv� ................... .
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Does applicant own property in any other If yes, what county? What T2 C81'd NO. ..... .... ...-: ,auested on
counry in Indiana? /`IS Oo0• Dd � �'�'� �7 Yes❑ No
COUNTY AUDITOR
Deduction approved in the amounl of:
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ignaWre County Auditor Dale
�'/ We certify under the penalty of perjury that the above and foregoing information is true and corred and that ihe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Si� ur (owner's 11 na e) Person authorized by duly executed Power of Attomey
_ �/f� or by IC 6-1.1-12-.07
Full r ys�� address of appli nt Address of authorized person
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