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� � STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
� FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
: J State Fwm a3709 (RS l 4-03) . p
+ ,.��,..�5:
��� Prascnbed by Department ol Loral Guvemment Finance �'
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INSTRUCTIONS: File Mark
To be filed in person or by mail with the Counry Auditor of the county where [he property is located. FEB 2 5 ZQQS
Filing Dates: 1) Real Property: During the 72 months betore May 11 0/ the year the deduction is to be e/fective. �
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year fliadaductiq� � o be eHective.
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See reverse side for additional instructionsaqd qualifications. t��
� �. Q�BSON COUN7Y AUDITOR
contract buyer - see
Taxing Disirict // Ke umber / legal description Record number ��
� ��,�� �j/� �� � �U Page number
�
Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or e
March 1, current year March 1, curr year owne(? ❑ Yes ❑ No
����?a �0
no, what is his / her exact share of interest?
If name on record is different lhan that of applicant,
mortgagee or conlract seiler
below:
Address of moAgagee or contrad seller (number and streef, �
Name of assignee or other owner or holder of mortgage
If owned with someone other than spouse, indicate with whom.
❑ Real Property ❑ Mobile Hane pC 67.1-�
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_ .J! l� ��
Drawer NO .:.................
Address of assignee (num6er and street,.city, state, ZIP code Card NO . .....................
Does applicant own property in any other If yes, what wunty %��— ,{ W�� /�� tion been requested on
county in Indiana? �
� N��pr�ry ror cunent yeaR� Yes❑ No
Deduction
20 oG,
1
Signature _
in the amount of:
20 O 20
Y
COUNTY AUDITOR
20
County Auditor
20
20
20
certify under lhe penalty of peryury that the above and foregoing information is We and correcl and thal the applicants was /were
lent of Indiana and owner of the aforementioned property on March 1, 20
(owners full nam@I}J� `
,�c1% p o T��J
address of a
�� S .
Person authorized by duiy executed Power of Attorney
or by IC 6-1.1-12-.07
of authorized person