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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION
���� I Sbte Form a3709 (RS 14-03)
Prescri�etl �y Department of Loral Gtivemment Finance
Coun Township Year
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INSTRUCTIONS: File Mark
To 6e filed in person or 6y mail wfth the County Auditor ol the county wbere the property is located. _ AP R � S ZQ�J
Filing Dates: 1J Real Property: During the 12 months be%re May 11 0l the year the deduction is to 6e eAective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0( the yea educt�iy to be effective.
See reverse side for additional instructions and qualifications. �
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Appucant ner rcontractbuyer- e re n
Taxing Distrid
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Assess d value o real prop y s of
March 1, current year
Ii no, what is his / her exact share of interest?
on r�v�e side)
Key number / legal description Record number
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Page number
Mortgage / Contract indebtedness unpaid as of Is the apptica� he sole legal or equitable
March 1, currenl year owner? ❑ Yes ❑ No
If name on record is different than lhat of applicant, indicate below:
Ii owned with someone other than spouse, indicate with whom.
e of mortgagee or contract seller / �
iti1.m ,�y�� o�U Q � � �
Address of mortgagee or contr sel r(number nd street, city, state,
Name of assignee or olher owner or holder of mortgage
of assignee (number and street, city, state, ZIP
Does applicant own property in any other If yes, what county?
county in Indiana?
Deduction approved in the amount of:
20 Yi {�
Signature
20 ��
COUNTY AI
20 a � 20 O�
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County Auditor
Is the
❑ Real Property ❑ Mobile Home QC 61.1-�
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20
20
� requescea on
? � Yes � No
20
certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
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resident address of applicant
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Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person