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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S�� ✓ State Fwm a3709 (RS / a-03) tp
� PrescriDetl by Depanment of Loc�al Govemment Finance ��j ,'_ ..
�.J
iNSrRUCnoNS: N0� 0 8 2005 Ma�x
To be �led in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1 J Real Property: During the 72 months 6efore May 11 of the year the deduciion is to be eJieF[iv� �
ii � �
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the?deductnlo9qgto be effective.
See reverse side /or additional instructions and qualifrcations. G�g50N COUNTY
or contract buyer - see
Taxing
Assessed value of real property as of
March t, curcent year
If no,-what is his / ber exact share
reverse side� -
Key nupi�er / le`gal description Record numberO�
U
� _ �y�/f��� �U Page number �j
C.tJ�
Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or e
March 1, wrrent year owner? ❑ Yes ❑ No
�7� �
If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant,
of mortgagee or contreG seller
Address of mortgagee or contrea seller (number and st��, city, stafe,
of assignee or other�owner or holder of mortgage
assignee (r
Drawer N.. Q�� S b
0 %..�. l Si
Does applicant own pr � �"""" nt Taxing Distnct?
county in indiana? �
Card NO. ...... Y .t..79�•,;:=
...._..... DITOR
approved in the amount of:
20 l l�l � 20 O Y
p
Signature
20 _Q`� 20 20
�
County Auditor
Is the property in question:
❑ Real Property ❑ Mobile Horne (IC fr1.7
�
Has this deduclion been requested on
property for current year?� Yes� No
�
20
We certify under the penalty of perjury that the above and toregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
address
2
.�
Person authorized by duly exewted Power of Attomey
or by IC 6-1.1-12-.07
of authorizzd person