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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
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�j State Fwm a3709 (RS I 4-03) ��� ry'
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� PresrnbeE by Department ot local Govemmeni Finance �j��
AUG U 1 2003
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor ol the county where the property is located. //��
Filing Dates: 1) Real Property: Dunng the 12 months be%re May 11 of the year the deduction is to be'�flecf;,,ve�
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the-year tAe�deducfion is to 6e� e, ective.
See reverse side for additional rnstructions and qualifications.
Applican nerorcont ct 6uyer- e rest ctio s n erse side)
Taxing Dislrid Key number/ legal description Record number0�
O// — �g� `�. �v Page number � j�
Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March i, wrrent year March 1, current ar owneR ❑ Yes ❑ No
If no, what is his / her exact share of interesl? If owned with someone other than spouse, indicate with whom.
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If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Horne (IC 61.1-�
�vne of moRgagee or contract seller ��
Address o( mortgagee or contract seller (nu er and street, city, state, ZIP
Name of assignee or olher owner or holder of mortgage ---- -
• Drawer NO. � � '� 7 � �
Address of assignee (number and street, city, state, ZIP code) •••• ............ .
Dces applicant own property in any other If yes, what county? ,• Card Np, ,,,,,,.,, requested on
county in Indiana? ? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 O Cc 20 �`L 20 �_ 20 �`L 20
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Signalure County Auditor Date
�� We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Si nature (owners full name) Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
Fuli resident address of applicant Address of authorized person
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