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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm a3709 (RS / 4-03)
Coun Township Year
� Prescn�ed by Department of Local Guvemment Financa
INSTRUCTIONS: ---File�Maric�
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To be filed in person or 6y mail with fhe County Auditor of the county where the property is located.
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Filing Dates: 1) Real Property: During the 12 months be(ore May 11 0/ the year the deduction Is o beyeNec ,tive.�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o(lhe year the deduction is to be effective.
See reverse side /or additional instructions and quali�cations. SEP 1 � 2�03
Applicant (owner o ntract buyer
Taxing Di d �
on
Key number / legal description
O/�— D�'7SS�
C!BSON
Record number
Page number
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3 CJ�I �
Assessed value of real property as of MoRgage / ContraG indebtedness unpaid as of Is the applipnt the sole legal or equitable
March 1, current year March 1, current year ownef? ❑ Yes ❑ No
. �V�OVV
If no, what is his / her exact share of interest? Ii 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 Property ❑ Mobile Home pC 61.1-�
Name of mortgagee or contrad seller
Address of mortgagee or conlrad seller (number a treet, city, state, IP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distnct? Has this deduclion been requested on
county in Indiana? property for current year?� YesO No
Deduction approved in the amount of:
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c.
Signature
20 �
7
COUNTY AUDITOR
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County Auditor
20 (i7ti 20 � 20
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Date
I/ We certify under the penalty of perjury that the above and foregoing information is irue and correcl and that the applicants was / were
`zsident of Indiana and owner of the aforementioned property on March t, 20
(owners full
address of
Person authorized by duly execuled Power of Attorney
or by IC 6-1.1-12-.07
of authorized person