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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
� �� / State Fwm a3709 (R5/4-03) � �
Presaibed by Department ot Local Govemment Finance � �� O �
� �LJ
�NSrRUCnoNS: MAR 2�e7�0�4
To be filed in person or by mail with the County Auditor of [he county where the property is located.
Filing Dates: 1) Real Property: During fhe 12 months be%re May 11 of the year the deduction is to e Hecth�e. l/J/
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0l the year�pe� duc�Non h� to. �"ef(ective.
See reverse side for additional instructions and qualifrcations.
Applican�t(%� nerorcontractbuyerJ-� e strictionson
Y.J///1/K� � l/ eee�i?,
Taxing Dislrid ' Key number / legal descripti Record number O�
l.� /
�, �n��/��� �/ �— ����—� Page number � ^a�`
(,`�' y CJ
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year ownef? ❑ Yes ❑ No
If no, what is his / her exact share
name on record is different than that of applicanl, indicate below:
If owned with someone other than spouse, indicate with whom.
of mortgagee or contract seller �/�
ss of mortgagee or wntract seller (num er and sfreet, city, state, ZIP
of assignee or other owner or holder oi mortgage
of assignee (number and street, city, state, ZIP
Is the property in question:
❑ Real Property ❑ Mobile Hortie pC 61.
Drawer NO ...................
i
CardN0..o3.� �S�
Does applicant own property in any other If yes, what county? Wha[ i axuiy viau���:
wunty in Indiana?
Dedudion
20
Signature
COUNTY AUDITOR
in the amounl of:
20 �., I 2� C� (� I Z� Q�
�
County Auditor
20
..__ .. _ _ _ . � requested on
property for wrrent yea(? � Yes ❑ No
20 � I 20
%i°
Date
/ We certiy under the penalty of perjury that the above and foregoing infortnation is true and corred and ihat the applicants was / were
�resideni of Indiana and owner of the aforemenlioned property on March 1, 20
Person authorized by duly execuled
or by IC 6-1.1-12-.07
of authorized person