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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
�' �" FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
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•• �,«. ! State Fwm 63709 (R5 / 4-03) . . . � � �. _j. J � + �
Prescn�etl �y Depanmeni of Local Govemment Finance p p
� OCT [ � 2004
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: i) Real Property: During the 12 months be%re May 11 of the year the deduction is to be effect�ve�. y
2) Mobile Homes assessed under IC 6-1J-7: Between January 15 and March 2 0( the year the�� uctr` on�rs�to;tie;effective.g
See reverse side /or additional instructions and quali�cations.
Applicant (owne� or cont cr� t 6uyer - see
� jij
Taxin Distri
Assessed value of real property as of
March t, curtent year
no, what is his / her exact share of interest?
If name on record is different lhan that
of mortgagee or contrad seller
on reverse
Key number / legal description Record number
a - � a s.�
D/ - O// _ � Page number
MoAgage / Contract indebtedness unpaid as of Is the applicant th ole legal or equitable
March 1, wrrent year owne(? Yes ❑ No
If owned with someone other than spouse, indicate with whom.
-�OD - �� /5`�-GYJ�
:anl, indicate below: Is�th/e�property in question:
. LJYReaI Property C7 Mobile Home pC Cr1.1-�
Address of moAgagee or contrad seller (number
of assignee or other owner or hoider of mortgage
city, state, ZIP
Address of assignee (num6er and strnet, city, state, ZIP code)
Does applicant own property in any other If yes, what counry? Wh Dra�'er Np. _-�•equested on
counry in Indiana? '•��- � ! � Yes� No
Card ND .. ��
, couNrv < ,
Deduction approved in lhe amount of: \� I�L
e1
20
Signature
20
20 �`� 20 0 y 20
P P
County Auditor
20
Date
20
a certify under the penalty of peryury that the above and foregoing information is true and corred and that the applicants was / were
ident of Indiana and owner of the aforementioned property on March 1, 20
t�e (owners lull name) Person authorized by duly executed Power of Attomey
�/, (,J�;,, or by IC 6-1.1-12-.07
:sident address of applicant Address of authorized person
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