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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALU�� Coun Township Year
: �«� ! State Fwm a3709 (RS / a-03) � � �
� PrescnEeA Oy Oepanmeni of Local Govemment Finance .
iNSrRUCnoNS: A�� 1 1 1005 F�ie Ma�
To 6e �led in person or by mail with the County Auditor of the county whe e the property is located. .�
Filing Dates: i) Real Property: During the 12 months be%2 May 11 0/ the�,! he� hon is to be eflective.
2) Mobile Homes assessed under IC 6-1.1-7: Betweer�J��r� 15�d fv� 2 0/ the year the deduction is to be eNective.
See reverse side for additional instructions and qualifications. COUNTY qUDITOR
Applicant (owne�orc tra buyer- s e restric ns o reverse side) ,
Taxing Distrid Key number / legal description Record number �
V I "I "ftl)aslo-� �� Pagenumber �
t l/ KJ � �
Assessed value oi real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March t, curtent year March 1, current year owne(? ❑ Yes ❑ No
t
If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate betow: Is the property in question:
❑ Real Property ❑ Mohile Hm�e (IC 61.1-�
�3me of mortgagee or contract seiler ,
Address of mortgagee or contrad seller (number and slieet, city, sta e ZfP
Name of assignee or olher owner or holder of mortgage - � -
Address of assignee (num6er and street, city, state, ZIP code) �
Does applicant own property in any other ii yes, what counry? What Taxing Distrid? Has this deduction been requested on .
county in Indiana? property for current year?� YesO No
" COUNTY AUDITOR
Deduction approved in the amount of:
20 � 20 �� 20 � 20 20 20 20
-� P
Signalure County Auditor Date -
�' We certify under the penalty of perjury that the above and foregoing information is true and corred and thal lhe applicants was / were.
a resident of Indiana and owner of the aforementioned property on March t, 20
ign r ner full name Person authorized by duly executed Power of Attomey
'� or by IC 6-1.1-12-.07 . .
i esi enl addre o ap licant Address of authonzed person
� � �