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�� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun
S�� / State Fwm a3709 (RS I 4-03)
� PfesaibeE by Department ot Local Gdvemment Finance
INSTRUCTIONS: �1
To be filed in person or by mail with the County Auditor of the county where the property is located. 'g
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to 6e ellect
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the
See reverse side for additional insfructions and qualifications. �'
Applicant (owneror nt ct bi
Taxing District
Assessed value of real propert
March 1, current year
restrictions on
Key num�i"er / legal
:,�, O Q -(6
as of MoAgage / Contract i
March t, currenl year
If no, what is his / her exaci share of interesl?
name on record is different than that of applicant,
of mortgagee or contrect seller
Address of mortgagee or contracl seller (number and
Name of assignee or other owner or holder of mortgage
of assignee (number and st2et, city, state, ZIP
below:
oscrip n Record number
��� � n\ Page number
V
ndebtedness unpaid as of Is the applii
owneR
�O
If owned with someone other than spousi
Is the property
❑ Real Prnce�
ciry, state, ZIP
Does applicant own property in any other I If yes, what county?
county in Indiana?
approved in the amount of:
20 �'�
�
Signature _
20
Taxing Distrid?
COUNTY AUDITOR
20 20 20
County Auditor
0
Year
F�e Ma� ��
�s
�t a is �effective.
I the sole legal or equitable
❑ Yes ❑ No
indicate with whom.
question:
❑ Mobile Home (IC 61.1-7
�� •��"3�'
�
�.• 08' j865
Has this deduc[ion been requested on�
property for current year? � Yes ❑ No
20
Date
20
''/ We certify under the penalty of perjury lhal ihe above and foregoing information is true and corred and lhat the applicants was ! were
: resident of Indiana and owner of the aforementioned roperty on March 1, 20 �
Signature (ow ll na e) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07 �
F ident a applicanl � y� Address of authorized person
'�.�e�' 3 3