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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�'. / Sute Form a3709 (R514-03) �
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PrescriCed by Departmeni of Laal Govemment Finance
INSTRUCTIONS: File Mark
To be filed in person or 6y mail with the County Auditor of the county where the �� 1 ated�
Filing Dates: 1) Rea/ Property: During the 12 months 6efore May 11 01 the year fh d tio is to e e i.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 a Ma e year the deduciion is to be effective.
See reverse side for additional instructions and qualifications. SE P� 5 2�03
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Applicant (ow ro t t buyer ee n n revers side)
-� ci ON COUNi�' �UDI70R
Taxing Di 'd Key umber / legal description Record number O
/ , / Q � / C —7 b �/� Page number � � �6
V � �J / ZIC,I
Assessed value of real property as of Mortgage / Contrect indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, enl year owne(? ❑ Yes ❑ No
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If no, what is his / her exacl share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicanl, indicate betow: Is the property in question:
❑ Real Property ❑ Mobile Hane QC 61.1-�
�me of mortgagee or contrect seller
Address of mortgagee or contract seller (number d st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and st�eet, city, state, ZIP code)
Does applicant own property in any other If yes, what wunty? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? propeAy for current yeaf? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in lhe amount of:
Zo io a� zo � zo c9� zo �_ zo � zo
$� � P P
Signature County Auditor Date
�/ We certify under the penalty of perjury that the above and foregoing information is true and corred and that the appiicants was / were
� resident of Indiana and owner of the aforementioned property on March 1, 20
Signatu o�/s f�d(I nar�G) _ n _ Person authorized by duly executed Power of Attomey
Q�1 U � f,�r^1.-� or by IC 6-1.1-12-.07
Full residenl address of applicanl Address of authorized person
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