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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
� �� / State Form a3709 (R5 / 4-03) ` _ �
PrescriDeO Gy Department o1 Local Govemmeni Finance 1� `� �
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To beR�ed�ln�person or by mail witA the Co ditor of the county wheie the prope�'k'loca'fe�oo� File Mark
Filing Dates: 1) Real Property: Dunng the 1 mo tbs be%re May 11 0( the year the deduction is to be eRective!'
2) Mobile Homes assessed under 6-1.1-7: Between January 15 and March 2,of the�year the,deduction is to be effective.
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See reverse side Ior additional inshuctions and qual�cations. ��jgSp4 C''- "
Appli owner or contract buyer- see strictions on reverse side
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Tauin Dislrid Key mber / legal description Record number Q
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Assessed value of real property as of MoAgage! Contrad indebtedness unpaid as of Is the applicant the sole leg I or equitable
March 1, wrrent year March 1, current year owner? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned wifh someone other than spouse, indicate with whom. '
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If name on record is different than lhat of applicant, indicate below: is the property in question:
❑ Real Property ❑ Mobile Home QC 61.1-�
�me of mortgagee or contraIX seller �/
Address of mortgagee or conVad seller (number and st2e't, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, sfate, ZIP code) `
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for wrrent yeaRO YesO No
COUNTY AUDITOR
Deduction approved in the amount of:
20 2 20 �� 20 �� 20 �q_ 20 20
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Signature County Auditor Date
We certify under the penalty of perjury lhat the above and foregoing infortnation is true and correct and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 7, 20
$ig�eeture owners /ull name) Person authorized by duly executed Power of Attomey
� or by IC 6-1 J-12-.07
ull resid a r s of app icant Address of authorized person
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