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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION
�' ! State Fwrt: 03709 (RS / 4-03)
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Prescnbed by Depanmeni o� Local Govemment Finance
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FII,EI�
Coun Township Year
1NSTRUCTIONS: File Mark
To be �led in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real P�ope�uri}g(�h�0e�nonths belore May 11 o/the year the deduction is to be eflective.
2) Mo6ile Homes assessed under IC 6-1J-7: Between January 15 and March 2 0� the year the deduction is to be el%ctive.
See reverse side !or
or contracf
• ,.
Assessed value of real property as of
March 1, current year
If no, what is his / her_exact share of interest?
If name on record is different than that of
me ot mortgagee or�contract seiler
Address of mortgagee or contrad seller
quali�cations.
'OR
�tions on rev side) _
n. ��f��
�i C�(� .
Key number / legal description
number
(� (� � ��3c�1''Dp 9 �
Pa e number b 50
Mortgage / Contrect indebtedness unpaid as of Is the applicant the sole legal or equitable
March t, current year owner? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
it, indicate below:
Se' �/�`�!—/ %! ��
and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other I( yes, what county? What Taxing District?
county in Indiana?
20 n b
Signature
aPproved in the amount of:
zo
COUNTY AUDITOR
zo �� zo 0 9
1 �
County Auditor
20
Is the property in question:
❑ Real Property ❑ Mobile Home (IC Cr1.1
Has this dedudion been requested on
propeAy for current year? � Yes ❑ No
zo
Date
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We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned propeRy on March 1, 20
name)
applipnl
Person authorized by duly executed Power of Attorney
or by IC 6-t.t-12-.07
of authorizad person