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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
� w/ State Fwm a3709 (RS / 4-03)
� PrascnDed by Department of Local Govemmem Finance
INSTRUCTIONS: File Maric
To be filed in person or by mail with the CountyAUditor of the county where the property is located.
Filing Dafes: 1) Real Property: During the 12 months before May 11 of the year the deduction is to be el%cfive.
2) Mobile Homes assessed under fC 6-1.1-7: Between January 15 and March 2 of the year the deduction is to be e(iective.
Jee reverse si0e Ior atlditional instructions and qualifications. ����
Applicant o ner or con� t buyer - see restrictions on reverse side) 0 CT 17 2003
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Taxing istrict Key number / egal description Recordmumber
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Assessed value of real prop as of Mortgage / ConVact indebtedness unpaid as of Is the applicant the sole legal or equit le
March 1, currenl year March 1, curtent year owner? ❑ Yes ❑ No5'► a 9
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is diHerent than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC E1.1-7)
�ne of mortgagee or contred seller �
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Address of mortgagee or wntract seller (number and street, city, state, ZIP Q' 1
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, ciry, state, ZlP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has lhis deduction been requested on
wunty in Indiana? property for curtent year? ❑ Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 �_� 20 _�_ 20 � 20
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Signature County Auditor Date
'' We certify under the penalty of perjury that the above and foregoing infortnation is true and correct and that the applicants was ! were
esident o( Indiana and owner of the aforemeniioned property on March 1, 20
ignature ( ner's /ull name) Person aulhorized by duly executed Power of Attomey
c or by IC 6-1.1-12-.07
ull resident address of applicant Address of authorized person
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