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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�. I State Form d3709 (RS / 4-03) - -
� Rescribed by Department of Local Govemment Finance � �
Coun Township Year
INSTRUCTIONS: � APR ���g C�
To be filed in person or by mail with the CountyAuditor of the county where the property is located.
Filing Dates: 1) Real Property: During fhe 12 montbs 6efore May 11 of the year the deduction is to be e/%ctive. �
2) Mo6ile Homes assessed under IC 6-1.1-7: Befween January 15 and March 2 0l tbe year th�d�gtio�i j;;to be eBective.
See reverse side for additional instructions and qualifications. G�ggpN COUNTV � iTOQ
or contract
Taxing Dislrid
on
/
� �04�/74��0 ' 4, ,
Assessed value of real property as of MoAgage / Contr d
March t, current year March 1, current
VQ�
If no, what is his / her exact share of interesl?
If name on record is diHerent than that of applicant, indicate below:
of mortgagee or contract
S
`-- ;
number
J Page number
a � �. �.::
as of Is the applicant the sole legal or equitable
owner? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
Address ot mortgagee or contract seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
of assignee (numberand street,
Does applicant own property in any other
county in Indiana?
state, ZIP code)
5�. .�F 2(�
Is lhe property in qu�
what county? � What Taxing Distrid?
COUNTY AUDITOR
)eduction approved in the amounl of:
20 �_ 20 �$_ 20 � 20 20
P P �
iignature County Auditor
❑ Real Property ❑ Mobile Home pC 61.1
Has this deduction been requested on
property for curcent year?0 Yes� No
�
20
certify under the penalty of peryury that the above and foregoing informalion is true and corred and lhat the applirants was / were
lent of lndiana and owner of the aforementioned property on March 1, 20
(owners full name)
Person authorized by duly executed Power ot Attomey
or by IC 6-1.1-12-.07
applicant IAddress of authorized person