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_ STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
` � FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�•'-�� � ! Stare Form d3709 (R5/4-03) . , - -�-�
Prescn�eE Cy Departmeni of Loral Govemment Financa { � 1 � .
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INSTRUCTIONS: �tY 1FIe�
To 6e filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During fhe 12 months before May 11 of the year the deduction is to be�etfecfive. � � � �
2) Mobile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 0/ theiyear the deduction is.to.be eNective.
See reverse side for additional instructions and qualifications. w,gcp f6U� � Y�u�'17O'� �
Applicant
Taxing uis(rici
buyer - see restnctions on revGr.ca �;.+a�
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Key number / �egal
Record n ber
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Page number
v v — c�
Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owneR ��s ❑ No
��o� GC�
Ii no, what is his / her exact share of interesl? If owned with someone other than spouse, indicate with whom.
If name on record is different than thaf of applicant, indicate below: Is the property in question:
eal Pmperty ❑ Mobile Hane (IC 61.1-�
Name of mortgagee or contract seller
� ress of mortgagee or contract s� r(n� d tr et, cit� y, state, ZIP
Name of assignee or other owner or holder of mortgage
,\ddress of assignee (numberand street, city, state, ZIP code)
Does applicant own property in any other I If yes, what county? What Taxing Distrid?
county in Indiana?
approved in the amount of:
20 � 20
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Signature _
COUNTY AUDITOR
E'31/S��f3]
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County Auditor
20
Has this deduction been requested on
property for current year?❑ Yes❑ No
7ao
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� 20 v !_ 20
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Date
I/ We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
tesident of Indiana and owner of the aforementioned property on March 1, 20
lull name)
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
IFull resident address of applicant // Address of authorized person
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