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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�+� w� ♦ State Form a3709 (RS / 4-03)
� Prespi�ed by Departmeni of Local Govammeni Finaxe
INSTRUCTIONS:
Coun Township Year
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/�VU 1 J 'FiYe�ark
To be filed in person or by mail wrth the Counry Auditor of the county whe2 the property is located. �
Filing Dates: 1J Real Property: Dunng the 12 mon[hs 6efore May 11 of the year fhe deduction�is to 6e effective,� ��
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2�of fiie�year th'e'deduction"is;ro 6e effective.
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See reverse side for additional instructions and qualifications.
Applicant
Ta�cing
� D.S- (� �/d0
see
Assessed vatue of real property as of
March 1, wrrent year
If no, what is his / her exacl share of interest?
Key number / I�gal description
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Mortgage / Contract'nd tedn
March 1�cenl year ! �
If name on rewrd is different than that of applicanl,
of mortgagee or contract seller
of mortgagee or contract seller (number and
of assignee or other owner ar holder of mortgage
Address of assignee (number and street, city, sfate, ZIP code;
Does applic 9 �
county in Irn (� � ...�
Drawer NO.........—.....
number
number
Is the applicant the sole legal or
owneR ❑ Yes ❑ No
owned with someone other than spouse, indicate with whom.
state, ZIP
What Taxing District?
.......
CaC(] NO. ..•...•...... • JTY AUDITOR
Deduction aF
20 �� 2o Q� 20 � 2o ap 20
_� � � �
Signature County Auditor
❑ Real Propertv � Mobile Home (IC Cr1.
Has this deduction been requested on
property for wrrent year?� Yes� No
20
Date
20
We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
residenl of Indiana and owner of the aforementioned property on March 1, 20
�natu(r� (onwners full name) �7 1 Person authorized by duly executed Power of Attorney
� 1 1L...._ �-�_ � �(n_ l. _ or by IC 6-1.1-12-.07
applicant Address of authorized person
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