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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
' F FOR DEDUCTION FROM ASSESSED VALUATION C To vear
ti. ! Sfate Fortn a3709 (R51 d-03) I
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PrescdOetl by Departmem ol local Govemment Finance
INSTRUCTIONS: File Mark
To 6e tiled in person or by mail with the CountyAuditor of the county whe�e the property is located. a�
Filing Dates: 1) Real Property: Dunng the 12 months belore May 11 of the year the deduction is to be eflective. (/ ��
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 oltbe ye���d�p/�kl9hT�� l6��@ctive.
See reverse side /or additional instructions and qualifications.
Applicant
Taxing District
see
� � `�-�CJLS�o.—G
Assessed value o( real property as of
March 1, current year
If no, what is his / her exact share of inierest?
�tions on reverse side)
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Key number / legal description Record number ,�
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O f �^ ^�a Page number �/ D
Mortgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 7, currenl year owner? �es ❑ No
C�o�oa
If owned with someone other than spouse, indicate with whom.
name on record is different than fhat of applicanl,
of mortgagee or contract
below:
of mortgagee or contract seller (number and sfreet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street, city, sfate, ZIP code)
Does applicant own property in any other If yes, what counry? I What
county in Indiana?
Oeduction approved in the amounf of:
20 � I 20
Signature
COUNTY AUDITOR
20 �� 20 0� 20
� P
County Auditor
the property in
❑ Mobile Hwne (IC 61.1-�
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Card•1�r�' . ` � /Q Y d on
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20
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' We certify under the penalty of perjury that the above and foregoing information is irue and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1. 20
�nature (ow (s full na ) Person auihorized by duly executed Power of Attorney
.������ ��,g�� or by IC 6-1.1-12-.07
Address ofauthorized person
S,