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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNE$�
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm a3709 (RS / 4-03)
Presdi�ed by Department of Laal Guvemment Financa
INSTRUCTIONS:
To be fifed in person or 6y mail with the County Auditor of the county whe2 the property is located. .
Filing Dates: 1) Rea/ Property: During the 12 months before May 11 0/ the year the deduction is to�� �ff�ti�e2005
2J.Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction is to be ef/ective.
See reverse side for additional instructions and quali�cations.
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Assessed value ofrealproperty as of
MarcF� 1, curtent year
If no, what is his / her exact share of interesl?
on 2verse side)
number / legal description
number
�/ �, ��� � v v Page number '
Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole lega or equitable
March 1, current year owne(? ❑ Yes ❑ No
owned with someone other than spouse, indicate wilh whom.
If name on record is different than ihat of applicant, indicate below:
�e of moRgagee or contract seller ��
Address of mortga9ee or contrad seller (n ber and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
assignee (number and sbeet, city, sfate, ZIP code)
--" --' ----�--���.�� anv.other I If ves, what.counry?
cou�
Drawer NO..�,,,,,,,,
Card NO. ... �.�y........
)ec
20 � I 20 �� I 20 �
/
Whal Taxing Distrid?
COUNTY AUDITOR
20
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County Auditor
20
s the property in question:
❑ Real Prop�iy ❑ Mobile Hmie QC Cr1.1-�
Has this deduction been requested on
property for wrrent yea(?� Yes❑ No
20
Date
20
ceAify under the penalty of perjury that the above and foregoing intormation is true and corred and ihat the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duiy execuled Power of Attorney
or by IC 6-1.1-12-.07
Full resident address of applicant � IAddress of authorized person