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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm d3709 (R6 / 5-06)
Presaibed by DepaNnanl of �oml Gwemment Finance
Coun Township Year
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INSTRUCTIONS: �F�aKd� �
To be Tled in person or by mail with the County Auditor of the county where the prope�ty is /ocated. �jJ ��
Filing Dates: 7) Real Property: Du�ng the 12 months before June il of the year fhe deduction is fo be e(fective.A^ n p�� aa�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Maich 2 of the year the de�llCtN s ective.
See reverse side for addifional instructions and quali(ications. ,�,„
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Applicant ( r r contract buyer - see tn'ction on reverse ' e) c 1O
Taxing is 'ct Key number / legal description Record number
(ID %
�\��(_!� � �Y��G '.7Oo?-LLZ�• /QO.Q� Page number
Assessed vatue of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, cunent year owner? � Yes � No
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If no, what is his / her exad share of interest? If owned with someone oiher than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in quesbon:
❑ Real Property � Mob�e Home QC G1.1-7)
M1�e of mortgagee or contract seller
Address of mortgagee or conUact seiler (num and street, crty, state, ZIP
Name oT assignee or other owner or holder of mortgage
Address of assignee (num6er and sbeet, city, state, ZIP code) -- �- -
Does applicant own property in any other If yes, what county? i ���" ��� i been requested on
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county in Indiana? i� I � t year? ❑ YesO No
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CardNO• ...............•�/
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DeducGon approved in the amount of:
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20 _Q7 20 �� 20 `�l �_ 20 20 20 20
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Signature County Auditor Date
I I We certiTy under the penalty of perjury that the above and foregoing infortnation is We and conect and that the applicants was / were
�sident of Indiana and owner of the aforementioned property on March 1, 20 .
�ature (ownels /ull name) Person authorized by duly executed Power of Attomey
�1�%� ��,���� or by IC 6-1.1-12-.07
Full resident address of applicant Address oi authorized person
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