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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�. J Suta Fwm a3709 (RS / 4-03) �
P2scriDed by Depanmeni of Lorvl Govemmem Finance
� ' '_.. � - . _..' y . . �
INSTRUCTIONS: � , File Mark ' � �
To be filed in person or by mail with the County Auditor oI the county whe2 the property is located. y. � '--' �-�
Filing Dates: 1) Real Property: Dunng the 12 months belore May 11 0/ the year the deduciion is to be eflective����
2) Mobile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 of the year the dedLtYion2is�to����ective.
See 2verse side /or additional instructions and qualifications. � , / J n /1
(owner or
Taxing Distrid
\
Assessed value of real properiy as of
March 1, current year
If no, what is his / her exact
description
number
�� / O �/ / � f QO Page number �
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Mortgage / Conlrad indebtedness unpaid as of Is the applicant the sole egal or e
March 1, curr ear owne(? ❑ Yes ❑ No
-6 C�C�O
If owned with someone other than spouse, indicate with whom.
If name on record is different ihan thaf of applicanl,
of mortgagee or contract seller
Address of mortgagee or contrad seller (number and stieet,
Name of assignee or other owner or holder of mortgage
of assignee (number and st2et, ciry, state,
below:
Does applicant own property in any other If yes, what county?
counry in Indiana?
20
Signature
approved in the amount of:
�
ZIP
What Taxing District?
Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1
Has this deduclion been requested on
property for current yea(? � Yes ❑ No
COUNTY AUDITOR
20 O� 20 D% 20 � 20 �_ 20
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County Auditor Dafe
/ We certify under lhe penalry of perjury that the above and foregoing information is lrue and corred and that the applicants was / were
Iresideni of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly execuled Power of Attomey
or by IC 6-1.1-12-.07
of authorized person
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