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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S . / State Fwm a3709 (RS / 4-03) � jjj ��� {j <��� �,- �
�M� Presui�ed by Department of Local Govemment Finance � �� �t-1 �
ed
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INSTRUCTIONS: SE File Ma�004
To 6e filed in person or by mail with the County Auditor of the county where the property is located. „
Filing Dates: 1) Real Property: During �he 72 months before May 11 of the year the deduction is to be e(�ective. J�
2) Mobile Homes assessed under IC 6-1J-7: Between January 15 and March 2 of tAe yeartt�ecded cu f on is to"be eff�ctive�
See reverse side for additional instructions and qualiFcations. �D GI°SOW CUL4fTY kL'D:7C:1 �
Applicant
`�./l.�xci��nc� �
Assessed value of real property as of
March t, current year
If no, what is his / her exact share of interest?
on
Record number Q
//1 /Q _ � �� / D_ .rJ'i Page number 2 'J `�
cv i co �J�J d a o
Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or
March 1, current year ownef? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
If name on record is different than lhat of applicant, indicate below:
re of mortgagee or contract seller �
Address ot mortgagee or coniract seller (number and street, ity, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numbe� and sf2et, city, state, ZIP code)
Is the propeRy in question:
❑ Real Property ❑ Mobile Home (IC 61.1
�yL�� � w .��! ��— r�7�,.2
�
Does a licant own ro e ����
pp p p rty in any other If yes, what counry? What Taxin Drawer NO.. ��r• ••••""' d on
county in Indiana? � ] No
CardNO . .....................
Dedudion approved in the amounl of:
20 J�_
Signature
20
COUNTY AUDITOR
20�� 20 U`
P P
County Auditor
20
�
Date
20
We certify under the penalty of perjury that the above and foregoing informalion is true and corred and that the applicants was / were
(�sident of Indiana and owner of the aforementioned property on March 1, 20
nalure ( wne/s ame) Person authorized by duly executed Power of Attomey
��_,' h� ��c� or by IC 6-7.1-12-.07
of authorized person