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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION n -Tow shi Year
�• ! State Fom: a3709 (R5/ a-03)
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Prescd0etl by Depanment of Local Govemment Finance
INSTRUCTIONS: File Mark
To be /iled in person or by mail with the County Auditor o) the county where the property is located. a�
Filing Dates: 1J Real Property: During the 12 months 6efore May 11 0/ the year the deduction i j$ be efleofi4 ��
2) Mobile Homes assessed under IC 6-1.1 •7: Between January 15 and March 2 o�7tA��r�b'(ic4r�i��i�QB be eHective.
See reverse side /or additional instructions and qualifications.
ract buyer -
���Q ��
Assessed value of real property as of
March 1, wrrent year
If no, what is
exacl share of interesl?
If name on record is different than that
o( mortgagee or contract seller
on
Key number /
side)
Record number ^ �
!- /
�� _ Q������ Page numbe
Mortgage / Conlract indebtedness unpaid as of Is the a
March 1, wrrent year ���� owner?
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Address of mortgagee or contred seller (number
indicate betow:
Name of assignee or other owner or holder of mortgage
Address of assignee (number and stieet, city, state, ZIP
Does appliwnt own property in any olher If yes, what county?
county in Indiana?
Deduction approved in lhe amount of:
zo
Signature
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t the sole legat or equitable
❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
state, ZIP
What Taxing District?
COUNTY AUDITOR
Is the
❑ Real Property O Mobile Hane pC 61.1-�
Has ihis deduction been requested on
propeAy for current year? � Ye50 No
�Drawer i�*p CJ �—�``��� -
20 2e C
0
County Auditor
ard ]VQ ,..
We certify under the penalty of perjury that the above and toregoing information is true and correct and thal lhe applicants was / were
resident of Indiana and owner of ihe aforemeniioned property on March 1, 20
Person authorized by duly executed Power ot Attorney
or by IC 6-1:1-12-.07
Full resident address of �plii`ant ` U Address of authorized person
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