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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
: �w� / State Form a3709 (RS 14-03) � � �
� Pascn�ed Ey Deparimeni of Loral Gtivemment Finance
INSTRUCTIONS: S�P 2 3��Mg�
To be filed in person or by mail with the County Auditor of the county where the property is locat /�
Filing Dates: 1J Real PropeRy: Dunng the 12 months befo2 May 11 of the year the deduction i 6e eB ti � Jj //!I ///�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o arlh�eUt1€lidn'rS-t�-9eteffective.
GI SON UNTY nl�plf6n �
See reverse side for additional insfructions and qualifications.
Applicant
buyer
number / legal description � Record number
�Q Page number v�
� 0/� C�%- B�� a,
Assessed value of real property as of Mortgage / Contrad indebledness unpaid as of Is the applicant the sole legal or equitable
March 1, cunent year March 1, current year owneR ❑ Yes ❑ No
Ii no, what is his / he�xac�har�f interest? If owned with someone other than spouse, indicate with whom.
n
name on record is diffe�efrt than that of applicant,
moRgagee or contraIX seller
Address ot mortgagee or contrad seller (number and street, city, state, ZIP
of assignee or other owner or holder of mortgage
assignee (num6erand street, city, state, ZIP
Does applicant own property in any other I If yes, what counry?
counry in Indiana?
Deduction approved in the amount of:
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1°v-z� ►3 0 �
Signature
property in questian:
❑ Real Property ❑ Mobile Horrie (IC &1.1-�
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4Vhat / � �ested on
�� �._,_�,Yes � No
COUNTY AUDITOR
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County Auditor
20 �_ 20 �� 20
P � P
Date
We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of lhe aforementioned property on March 1, 20
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esident address of app�icant
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Person authorized by
or by IC 6-1.1-12-.07
of authorized person
of