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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
' FOR DEDUCTION FROM ASSESSEO VALUATION Coun Township Year
�'. �� / State Fwm 63709 (RS / 6-03j .
� PreSCriDed by Departmeni of Local Gtivemment Finance
INSTRUCTIONS: g F' e �t�r� �
To be filed in person or by mail with the County Auditor of the county where the propeRy is located. �� �� �
Filing Dates: 1) Real Property: During the 12 monfhs befo�e May 11 0l the year the deduction is to be ectiv
2) Mobile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 0/ the year he educ ion is o e e ective.
See reverse side /or additional instructions and qualifications. N Q � 2 2 2�04
(owner or contract
Assessed value of real property as of
March t, wrrent year
no, what is his / her exact share of interest?
Key number / legal description Recor� numbe ���
�� / � �o Pagenumber� I � �
� '
Mortgage / Contract indebtedness unpaid as of Is the applicant t¢e sole legal or e
March 1, currenl year owneR C� Yes ❑ No
4 �
If owned with someone other than spouse, indicate with whom.
If name on record is different lhan that of applicant, indicate below:
�me of mortgagee or conlract selier I �
of mortgagee or contrad seller (number and st2et,
Name of assignee or olher owner or holder of mortgage
Address of assignee (num6er and st2ef, city, state, ZIP code)
Does applicant own property in any other I If yes, what county?
county in Indiana?
Deduction approved in the amount of:
20
Signature
20
state,
- .3- -" o0-�U./��-Q6�'
Is the property in question:
_ ❑ Real PmpeAy O.Mobite Home QC 61.1
/ • �/L
Taxin ��"����
9 DrawerNO.••�••••'
� � 3 � ......
Card NO. ••� �1' OOv
COUNTY AUDITOR
20 �_ 20 _Q�
P P
County Auditor
3
20
Date
�
d on
� No
We certify under the penalty of pe � ry that the above and foregoing infortnation is true and corred and that the applicants was / were
�side Indiana and owner of e aforementioned property on March 1, 20
ure ( ners (ul e) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07 .
I s nt address of applicant Address of authorized person