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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�`�„'•. - w� / State Fortn <3709 (RS / a-03)
�� PrescnDetl Dy Department ol Laal Govemment Finance
Coun Township Year
� beRU aTIOP �on or by mail with the County Auditor of the county where the property is located. �� File� �
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Filing Dates: 1) Real Property: During the 12 months be)ore May 11 0/ the year the deduction is to be effe�ji
2J Mo6ile Homes assessed under IC 6-1.1 J: Between January 15 and March 2 0/ the year tFi���duct�n��be effective.
See reverse side for additional instructions and quali�cations.
Applicant(ownerorcont t uyer-seerestnction rever si e) , �
Taxing Distrid Key number / legal descri i Record number Q�
I / j� D�/� r O/� Y6 � J l Page number
W I\ E� O L� �. �J
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 J/�1' �7� owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different lhan that of applicant, indicate below: Is the property in question:
❑ Real PropeAy ❑ Mobile Home pC 61.1-�
��ne of mortgagee or contrad seller �
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Address of morigagee or wntrect seller (number and stieet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand street, city, state, ZIP code)
Does applicant own property in any other If yes, what wunty? What Taxing District? Has this deduction been requested on
county in Indiana? property for current year? � Yes � No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 Q_ 20 Q 20 20 20 20 •
�. � Y
Signature County Auditor Date
�'� We certify under the penalty of perjury lhat the above and foregoing infortnation is true and corcect and thal the applicants was / were
asident of Indiana and owner of the aforementioned property on March 1, 20
S' na r owners 11 na Person authorized by duly executed Power of Atlomey
or by IC 6-1.1-12-.07
ul i dress of applicant Address of authorized person
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