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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm a3709 (RS / 4-03) .
PrescriDed �y Department of Loral Govemment Finance
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INSTRUCTIONS U� i 1 �i
To 6e Rled in person or 6y mail with the County Auditor o) the counry where the property is located. �
Filing Dafes: 1) Real Property: During the 12 months belo2 May'11 oI the year the deduction is to 6e effective. rn!�
2) Mobile Homes assessed under IC 6-1.1J: Between January 15 and March 2 0/ the ear thelt ��t�is�to be`e�(ective.
G�BSON 1 hU�!TOk �
See reverse side /or additional insfructions and qualifications. COUt��
or
see r� tri ions on rse side)
Key number / legal de
Record number
� D I�' -0 3 49 0-d o Page number �4/�
/
Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrrenl year March 3scurrent year ownef? ❑ Yes ❑ No
c�R � / D �
ii no, what is his / her exacl share of interest? If owned wilh someone other than spouse, indicate with whom.
If name on record is different than that of applicanl, indicate below: Is lhe property in queslion:
of moM1gagee or contract seller
Address of mortgagee or contrad selier (number and st2et, city, state,
Name of assignee or olher owner or holder of mortgage
of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other It ���- " q 4% � ��?
county in Indiana? l � �'""'
Drawer NO�..
Deduction approved in the amount of:
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Signature
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Ca�d Np, ..
20 � „ 20 �Lo 20 �$
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County Auditor
❑ Real Property ❑ Mobile Home pC &1.1-�
Has this deduclion been requested on
property for curcent yea(? � Yes ❑ No
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Date
/ We certify under the penalty of peryury that the above and foregoing information is true and corred and that the applicants was / were
�resident of Indiana and owner of the aforementioned property on March 1, 20
gnature (owners full name) Person authorized by duly executed Power of Attorney
��� _ . i � _ _ ,M _ n _ or by IC 6-1.1-12-.07
address of appA�nt' (\ �Address of authorized person