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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
SUte Fortn a3709 (RS / 4-03)
PrescAbed �y Department ot Loral Govemment Finance
INSTRUCTIONS:
Coun Township Year
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To be �led in person or by mail with the County Auditor of [he county where [he property is located.
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Filing Dates: 1) Real Property: During the 12 montAs befo2 May 11 of the year the deduction is to�tie ef(ective. /�
2) Mobile Homes assessed under IC 6• 1.1-7: Between January 15 and March 2 of th,ce��y�e,a��r �th�e,.,d�eductio�n 'is�to� /b`e efJf�ective.
See reverse side for additional instructions and uali�cations. �'� -- vf "���'"�"`�'--(
9 GI3SOH COU'Jry H�iD1TGR I
Applicant (owner or contract 6uyer- see restrictions on reverse side)
Taxing Distrid Key number / legal description Record number
3
� Page number
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, currenl year owneR [�es ❑ No
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If no, whal is his / her exaci share of inleresl? If owned with someone other than spouse, indicate with whom.
If name on record is different than ihat of applicant, indicate below: Is the property in question:
Property ❑ Mobile Hame QC G1.1-�
" me of moAgagee or coniract seller
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Address of mo agee or contract seller (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage �
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Address of assignee (num6erand street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for cunent year? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 i 20 20 20 �� 20 O Q 20
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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 thal the applicants was / were
resideni of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners full name) Person authorized by duly executed Power of Attomey
' or by IC 6-1.1-12-.07
Fu I resident address of applicant Address of authorized person
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