HomeMy WebLinkAboutMortgage_Brackett��� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
� FOR DEDUCTION FROM ASSESSED VALUATION
�� ! Sute Form a3709 (R5/ d-03)
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PrascnbeE by Depanment of Local Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the CountyAUditor of the county where the property is localo�.
Filing Dates: i) Real PropeRy: Dunng the 72 months be%re May 11 of the year the deduction is to be el/ective.�AA� ���n�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0l the year the de�uct on is L�ective.
See reverse side for additional instructions and qualifications.
contract
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see
Assessed value of real property as of
March 1, wrrent year
on
Key number eg esc(ption Record nurt
0 T-oaa�l�O agenumbi
Mortgage / ContraG indebtedness unpaid as o�j Is the a
March t, wrrent year }�� o� owner?
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If no, what is his / her exact share of interesl? -�
If name on record is different than thal of applicant, indicate
of mortgagee or contract seller
Address of mortgagee or contract seller (number and street, city,
aoo s - �,'.x 7
DrawerNO ...................
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Card NO . .....................
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Deduction approved in the amount of:
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Signature
20 � I 20
nortgage
ctate, ZIP
O'/a� .G�
[ the sole legal or equitable
❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
Is the property in question:
❑ Real Property ❑ Mobile Hwne (IC frt.
:, what county? I What Taxing District? Has this dedudion been requested on
property for current year? � Yes � No
COUNTY AUDITOR
20 0 9 zo
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Couniy Auditor
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Date
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We cerfify under the penalty of perjury that the above and foregoing information is true and wrred and thal lhe applicants was / were
;esident of Indiana and owner of the aforementioned property on March 1, 20
(owners tull na e)
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ent addres f applicant
� � C'�O � �`
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Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
of aufhorized person