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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�'• �«� ! State Form a3709 (R5/ a-03) , �
� PrescnDed by Departmeni ot Local Govemment Finance ��
INSTRUCTIONS: NQ� 1 b 2�04 File Mark
To be filed in person or by mail with the County Auditor o/ the county where the property I� Tocated.
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the uchon is b ffectiv
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 an arch r t ion is to 6e effective.
See reverse side for additional instructions and quali�cations. G�ggON CQ�� TY 4UDITOR
Applicant (owner or contract ye - see restnctio rse 'de •
Taxing Dislrid Key num er legal descri ' n Record number v�
OI (�/ _ �OQ/ / � Page number � ^
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Assessed value of real property as of Mortgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, cunent year March 1, current year owneR ❑ Yes ❑ No
�� VV �/
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 than lhat of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Hane (IC 61.1-�
�ne of mortgagee or contraU seller �
-5 3
Address of mortgagee or contrad seller (number and stieet, city, state, ZIP
Name of assignee or other owner or holder of moAgage "
Address of assignee (num6er and street, city, state, ZIP code)
Does applicanl own property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for wrrent year?� YesO No
COUNTY AUDITOR
Deduction approved in the amount of:
zo n- zo � zo �_ zo � zo zo zo
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Signature County Auditor Date
�We certify under the penalty of perjury lhat the above and foregoing infortnation is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature ers a ) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
ull eside address of applicant � Address of authorized person
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