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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
State Fwm d3709 (RS / 4-03) �
Piesaibed by Department of Local Govemment Finance
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wsrRUCnoNS: FEg g����85
To 6e filed in person or by mail with fhe County Auditor of the county whe2 the property is located. �
Filing Dates: 1) Real Property: During fhe 12 months belore May 11 of the year the deduction is to be efle tl' �e,,.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 75 and March 2 olthe year th4ldc�droti��6e eHective.
See reverse side for additional ins[ructions and quali�cations. p�$$ON COUNTY AUDITOR
orcont cf
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Tauing Distrid
Asses€ed val�E of real
March 1, curcent year
see 2stnc ns on reverse
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Key number / legal
- ��- 0�'�'9-�d
as of Mortgage / Contract indebtedness unpaid as
March 1, currenl year
If no, what is his / her exact share of interest?
If name on record is different than ihat of app ca t, indicate below:
�me of moRgagee or contrad seller
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Address of mortgagee or contrad seller (number and street, city, s
Name of assignee or other owner or holder of mortgage
Address of assignee{num6erand st2et, city, state, ZIP code)
Record number
Page number
Is the applicant the sole legal or
owner? ❑ Yes �❑ No
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If owne with someone other than spouse, indicate wilh whom.
ZIP
Does applicanl own property in any other I( yes, what county? What Taxing Distrid?
county in Indiana?
Draw /''�-��' T^R-
Deduction approved in the amounf of: er NO� �-"' ••��5. �%
Card i1'O. . / _
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Signature
County Auditor
s the property in questfon:
❑ Real Property ❑ Mobile Hane (IC 61.1-�
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Has this dedudion been requested on
property for wrrent yeaf? � Yes ❑ No
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Date
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' We certity under the penalty of perjury that the above and foregoing information is lrue and corred and that lhe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Full
ot
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Person authorized b�
or by IC 6-1.1-12-.07
executed Power of Attomey
person