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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSFSSED VALUATION Coun Township Year
Sp2e Form a3709 (R5 / a-03)
Prescribed by Department ol Local Govemmem Finance � �� � .
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INSTRUCTIONS: N O V U 6 20��e Mark
To be filed in person or 6y mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: Dunng fhe 12 months before May 11 0/ the year the deductionis to be effective? "
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Marc 2 of t�he� y��ea/r �he deductio�is to be effective.
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See reverse side for additional instructions and quali(cations. GiBSON CpUN i Y��in�TOR
Applicant (owner or contract
Taxing District
Assessed value of real property 2s of
March 1, current year
restrictions on reverse
no, what is his / her exact share of interest?
Key number7 legal desuidtfon I Record number
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,/y� l�f _O /n I // � � Page number � � �qy
C�V � � 7 Y i� a/
Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owner? ❑ Yes ❑ No
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If owned with someone other than spouse, indicate with whom.
If name on record is diHerent than that of applicant, indicate below:
e of mortgagee or conhad seller
Address of mortgagee or contracl selier mber and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street, city, stafe, ZIP code)
Does appiicant own property in any other If yes, what countv?_ , What Taxing District?
counry in Indiai � ^ _ � � � �
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���'E'MI �� VTY AUDITOR
Deduction appr / „/�it.c�-r�.¢.,
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r� If►� �Ld � � rl� �
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County Auditor
s the property in question:
❑ Real Properry ❑ Mobile Home (IC 61.1-7)
Has this deduction been requested on
property for current year? ❑ Yes❑ No
20
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certify under the penalty of perjury that the above and foregoing information is true and corcect and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
address
`
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Address of authorized person
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