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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNE3�
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm a3709 (RS / d-03) � � � . , . � '
PrescnEM Dy Department of Loral Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor ot the county where the propeRy is
Filing Dates: 1) Real Property: During�the 12 months be%re May 11 0/ fhe year the deduction is to be e(!�tive. ���n4
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year }�ie ded ct 4s to be effective.
See reverse side for additional instnictions and quali�cations.
buyer- see restnctions on
Assessed value of real property as of
March 1, current year
no, what is his / her exact share of interesl?
G(5SON
side)
Key number / legal descripti6d Record number
Q ( � � Q IS � � � Page number �
Mortgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owne(? ❑ Yes ❑ No
If name on record is different lhan thal of appliwnt, indicate below:
�ame of moAgagee or contrad seller ^
.
t Q%A.6.t�
Address of mortgagee or contract seller (number and str , city, s
Name of assignee or other owner or holder of mortgage
If owned with someone other than spouse, indicate with whom.
Address of assignee (numbe� and street, city, atate, ZIP.code) � .
Does applicant own property in any other I if yes, what counry %
i
county in Indiana? ,
Deduction approved in the amount of:
20 D�. 20 20 _Q�
r�' p,
Signature
ZIP
lN`at Taxing District?
COUNTY AUDITOR
2c
County Auditor
Is
❑ Real Property ❑ Mobile Home (IC Crt.
Has this deduction been requested on
property for current year? �] Yes � No
zo 09 � zo
Date
zo
/ We certify under the penalty of peryury that tFe above and foregoiny information is true and corred and that ihe applicants was / were
�resident of Indiana and ovrner of the aforemer;tioned propeiy on March 1, 20
(owners full
�1
Person auihorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person