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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
: �� / State Fwm o3709 (R5 / a-03)
� PrescriEed by Department of Loral Govemment Finance
INSTRUCTIONS: File•Nta'flc �
To be filed in person or 6y mail with the County Auditor o/ the county where the property is located. � �� �}"'{ ��}
Filin Dates: 1 Real Pro e Dunn the 12 montAs before Ma 11 of the ��
9 ) P rtY' 9 y year the deduction is to b� e(fect� y�/
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Ma�ch 2 of the �r the deduction is tQ� ¢e e/%ctive.
See reverse side Ior additional instructions and qualifrcations. AD R � 2�uT
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Applicant(ownerorcon tbuyer-s �estnction�reve side) u„�^,i,.�YU°Y����,T�-
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Taxing D' 'cf Key number / legal description cord number �^�
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Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, wrrent year owneR ❑ Yes ❑ No
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If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different ihan that of applicant, indicate below: Is lhe property in question:
❑ Real Property p Mobile Hmie (IC Cr1.1-�
�me of mortgagee or contrad seller � � � �
Address of mortgagee or contract seller (num er and st2et, city, , Z
Name of assignee or other owner or holder of mortgage
Address of assignee (number and stieet, city, state, ZIP code)
Does appliqnt own property in any other If yes, what county? What Taxing Distrid7 Has this dedudion been requested on
county in Indiana? property for current year? � Yes � No
COUNTY AUDITOR
Deduction approved in the amount of:
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Signature County Auditor Date
��/ We certify under the penalty of perjury that the above and foregoing information is true and corred and that ihe applicants was / were
� resident of Indiana and owner of the aforementioned propeRy on March 1, 20
Si ature (owner 11 name) Person authorized by duly executed Power of Attomey
. or by IC 6-1.1-12-.07
Fu esi�nt address of plicani ^ . Address of authorized person
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