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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUi4TION
State Fwm a3709 (RS I 4-03) -
PrescriDeE by Department of Local Govemment Finance �
Coun Township Year
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INSTRUCTIONS: File,pq�
To be filed in person or by mail with the County Auditor of the county where the property is located. � � N 1�4 LUU4
Filing Dates: 1 J Real Property: During the 12 months 6efore May 11 0/ the year the deduciion is to be eflective. ��� n
2) Mobile Homes assessed under IC 6-7. 7-7: Between January 15 and March 2 0/ the year the �ded��uc�tio`n is to be e ective.
See reverse side for additional instructions and qualifrcations. .•r�nN ; SCi ih/TY FUv17G`t i
Applicant (owner or
;ing Distrid
buyer-
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Assessed value of real property as of
March 1, current year
on r�✓erse side)
Key number l legal
Record number
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O/n_O/� ��_ GG Pagenumber ��/
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Mortgage / CoNreU indebtedness unpaid as of I Is the appticant the�ole legal or equitable
March 1, current ye2r ownef? G✓ Yes ❑ No
I / �O �Od �Q �
If no, v�hat is his / her exact share of interesl? If owned with someone other than soouse, indicate with whom.
If name on record is different ihan that of applicant, indicate below: Is the operty in question:
o! moAgagee or conlracl seller
of mortgagee or contreci seller (number and street, city, state. ZlP
of assignee or other owner or holder of :nortgage
Address of assignee (number and street, ciry. s;a!e, ZIP code)
Does applicant own property in any ether I I; yes, what countj % i ��'Vh2! ��a
wunty in Indiana? � ��,
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3 COUNTY AUDITO
in ihe amount of:
20 �0 20 � 20 _� 20 O'
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Couniy Auditor
v ❑ Mobile Home
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20
Date
�een requested on
year?� Yes� No
20
/ We certify under the penalty of perjury that ihe abo�:e and feregoin� information is true and correct and that ihe applicants was / were
resident of Indiana and owner of the aforemer.tioned property on March 1, 20
lull name)
Full resident addre�s of
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Person authorized by duly executed Power of Attorney
or by IC 6-1 J-12-.07
of authorized person