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n�� STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
' z FOR DEDUCTION FROM ASSESSED VALUATION C n Tow Year
�'• M / State Fwm a3709 (R5/ a-03)
� PrescnDeO �y Department ol Local Govemment Finance � �G
INSTRUCTlONS: File Mark
To be filed in person or by mail with the County Auditor of the county where the property is located. a�
Filing Dates: 1) Real Property: Dudng the 72 months before May 77 of the year the deduction is to 6e K,� Qtive. C/ ��
2) Mo6ile Homes assessed under IC 6-1JJ: Between January 15 and March 2 of the ye�'fln���iTi� t������tive.
See reverse side for additional instructions and qualiFcations.
Applicant (owne�or
oistria
Assessed value ofrea
March 1, currenl year
as o(
on
Key number / legal description Record numb
�--� ����— � Page number
Morlgage / ContraG indebtedness unpaid as of Is the apl
March 1, current year � owner?
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d
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int the sole legal or equitable
❑ Yes ❑ No
0 U U
If no, what is his / her exact share of interesi? If owned with someone other than spouse, indicate with whom.
I( name on record is diHerent than thal of applicani, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Hane (IC 61.7
�me of mortgagee or contrad seller
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Address of mortgagee or contrad selier (number d street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numbe� and street, city, sfate, ZIP code)
Does appliwnt own property in any
county in indiana?
20
SignaWre
approved in the amount of:
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If yes, what county?
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Ca�a��
COUNTY A ,rt
20 20 0 20
P P
County Auditor
20
Date
en requested on
..., � ent year? � Yes � No
20
We certify under the penalty of pery'ury ihat the above and foregoing information is Irue and correct and that the applicants was / were
resident of Indiana and owner o( the aforementioned property on March 1, 20
3nature (o/�yners (ul ame)/ Person authorized by duly executed Power of Attorney
1�.�f' y' „_ ., st— o� bY ic s-,.,-,2-.0�
addres1s ot applicant ��^ ¢76t.0 IAddress of authorized person