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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION
1 w/ Sute Fwm a3709 (RS / 4-03)
PrescnDed by Department of Local Govemment Finanm �
•
INSTRUCTIONS:
To be filed in person or by mail with the CountyAUditor of the county where fhe property is Iocai��qY 2 g 2004
Filing Dates: 1 J Real Property: During the 12 months be(ore May 11 0/ the }rear the deduction is to 6e el%ct�ve.
2) Mobile Homes assessed under lC 6-1.1-7: Between January 15 and Ma 2 of the ye fhe deduct/io/n is/ to be effective.
See reverse side /or additional instn�ctions and qual�cations. � . i�� ,.,//. , l�
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contract
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Taxing
restrictions
Key number / legal description
�b/- 90�'�� -�U
Record number
Page number
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrrent year March 1, current year owneR ❑ Yes ❑ No
/�� Q�U
If no, what is his / her exad share of interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
�me of moRgagee or contred seiler ��
Address ot mortgagee ar contract seller (n ber and sf2et, city, state, ZIP
of assignee or other owner or holder of mortgage
st2et, city, state, ZIP code)
�_v3oo - 600. 9�
Is the property
❑ Real Proper
-GQ/
❑ Mobile Home (IC &1.
Does applicant own property in any other If yes, what county? \ :n requested on
county in Indiana? /32 e� 0�- e�ra aR� YesO No
�De�N�2
couNrr a �o � — d�'�� S/-�°S°
Deduction approved in the amounf of: /.tej� yysD. Od ��`'���-��
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20 U� 20� 20 0�
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County Auditor
�
Date
20
/ We certify under ifie penalty of perjury that the above and foregoing informalion is true and corred and ihat the applicanls was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized b�
or by IC 6-1.1-12-.07
of authorized person