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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNES�
FOR DEDUCTION FROM ASSESSED VALUATION
Sute Fwm a3709 (RS / a-03)
Prescribed by Departmeni of Local Govemment Finance f
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INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of fhe county where the property is locate�� �� Z 2��3
Filing Dates: 1) Real Property: Dunng the 12 months betore May 11 0/ the year the deduction is to /fe t e.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2�0/ the year tAe d(e�duction is to 6e effective.
See reverse side for additional insWCtions and quali�cations. ��,��,V�� ��/�!�M`%
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G:3SON CIOUNTY AUDtTOR
Applicant (ownerorcontract b r- resMctio reverse side)
Taxing Distrid Key number / legal d Record number �
�/ % � l�/ �O Page number / � � �
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrtent year March 1, current year owneR � Yes ❑ No
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If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate wilh whom.
If name on record is different than that of applicanf, indicate below: Is the properiy in question:
❑ Real PropeAy ❑ Mobile Home QC 61.1-�
�Name ot mortgagee or contraG seiler � �
Address of mortgagee or contreG seller (number and stre t, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand street, city, stat,- --
......
.........
Does applicant own propeRy in any other If yes, wi Dra���eC \ ��� / this deduction been requested on
county in Indiana? .O 3.. � a CS .y �Ay for wrrent year?0 Yes� No
Card \O . ..............
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Deduction approved in the amounl of:
zo b Zo zo � Zo D'1 zo o t zo �_ zo
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SignaWre County Auditor Dafe
I/ We certify under the penalty of perjury that the above and foregoing informalion is true and corred and ihat the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
" nature (owners lull name) Person authorized by duly executed Power of Attorney
��� ec � or by IC 6-1.1-12-.07
II resident address of applica t Address of authorized person
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