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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Townshi Year
�+ «. / State Fortn a3709 (R516-03) �
� PresaiEed by Department of Local Govemment Finaxe �
wsrRUCrioNS JAN 2 5 2006
File Mark
To be filed in person or by mail with the County Auditor of the county where the property is located. �-y,, �
Filing Dates: i) Real Property: Dunng the 12 months before May 11 0/ the year the deduciion is to be eflective0'�a
• 2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year ��I� ,�t'������ve.
See reverse side for additional insfructi�s and qualiTcations.
(owner or contract
i axing uistn � ' Key number / leg2i on Record numbe
� -C� -/G - 03. 3 /9
C _ - �a Q Pagenum
� QT
Assessed value oi real prop as of Mortgage / Contrad indebtedness unpaid as of Is the lia
March 1, current year March 1, current year owneR �
SS00��..,
It no, what is his / her exad share of interest? If owned with someone ofher than spouse,
If name on record is different than that of applicant, indicate below: Is the prope�
of mortgagee or conlract seller
Address of mortgagee or contract
street,
Name of assignee or other owner or holder ot mortgage
Address of assignee (number and stieet, city, state, ZIP
applicanf own property in any other I If yes, what county?
� in Indiana?
Deduction approved in the amount of:
20 _j��_ 20 � 20
.. Ai� f
�
Signature
�
What Taxing District?
COUNTY AUDITOR
20
County Auditor
�
/�O
d the sole legal or i
with whom.
� Mobile Home (IC 61.1-
Has this deduction been requested on
property for wrrent year? � Yes ❑ No
E�]
Date
20
certify under the penalty of perjury that the above and foregoing information is true and correct and lhal ihe applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
name)
Person authorized by duly executed Power of Attorney
or by IC 6-7.1-12-.07
of authorized person