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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm a3709 (RS / d-03j .
Prescri0ed by Department of local Govemmeni Finance
INSTRUCTIONS:
To be filed in person or 6y mail with the County Auditor of the counry where the property is located. 7 ����A�
Filing Dates: 1) Real Property: Dunng the 12 months belore May 11 af the year the deduction is to be eR�iJe.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deductiori�is to be eff tive.
See reverse side for additional instructions and qualifications.
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\ � P�OOO�U!�f7 AU�Ifi �
or contract buver -
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Assessed value of real property as of
March 1, cunenl year
on 2ver,�se side)
number / legal
�i9- oo���-�
number O 2
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Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or
March 1, current year owner? ❑ Yes ❑ No
If no, what is his / her exacl share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is diHerent than that of applicant, indicate below: Is the property in question:
❑ Real Properry ❑ Mobile Home pC S1.
�me of mortgagee or contract seller �� J//��
Address of mortgagee or contract seller (nu er and street, city, state, 21P
Name of assignee or other owner or holder of mortgage
and street, city, state, ZIP code)
Does applicant own property in any
county in Indiana?
Deduction approved in the amount
20
Signature
20 D,�
It yes, what counry?
Dr - -
awerN�••.�1 ` _
Card�,o .� :�P�p�
COUNTY AUDITOR
20 �� 20 0
1
County Auditor
:en requested on
�ear? ❑ Yes � No
20 c �x 20 � 20
P p
Date
We certify under the penaliy of perjury that the above and foregoing infortnation is true and correct and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12•.07
resident address of a�plicant �Address of authorized person .�