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t STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
= FOR DEDUCTION FROM ASSESSED VALUATION C un ov� shi` Year
•-�w� ! Sute Fwm 43709 (R5 / 4-03) LJ
� Presuibed by Department ot Local Govemment Finance E p p� 2005 .�
INSTRUCTIONS: `-7ma�„ �(jFjY.Maric
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To be filed in person or by mail with the County Auditor ol the county where the property is located. a TY UDITOR
Filing Dates: 1) Real Property: During the 12 months be%re May 11 of the year the deduction is (gl@8@He6�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction is to be eHective.
See reverse side for additional instructions and qualifrcations.
Applicant (ow e orcon�ct buyer- see r 'ctions n e erse sid �
Taxing Distrid ' Key number / legal description Record number ��
i� Q� �-��� ��-�� Page number ��Gi
Assessed value of real property as of Mortgage / ContraU indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year ��' �� / owner? ❑ Yes ❑ No
It no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
G- v-aa- T��C�. ai3_�3
If name on record is differeni than tF�at of applicant, indicate below: Is the property in question:
❑ Real Propeiiy ❑ Modle.Home (IC &1 J-�
�3me ot moAgagee or contraci seller , _ - —
Addrzss ot mort a ee or contract seiler mber and et, cit , statr ��"� �
9 9 ( Y Dra�r�er NO......
�� ���
Name of assignee or other owner or holder of mortgage Card NO• •••••••••••"""""
Address of assignee (number and street, city, state, ZIP code) .
Does applicant own property in any other If yes, what counry? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for wrrent year?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amounf of:
20 20 20 20 20 20 20
� � I l�
SignaWre County Auditor Date
�/ We certiy under lhe penalty of perjury that the above and foregoing intormation is true and correcl and that the applicants was / were
a resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners full name) Person authorized by duly execuled Power of Attomey �
' � or by IC 6-1.1-12-.07
F I resident address of applicant Address of authorized person
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