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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION To ip — Year
: w� ,� Siate Fwm 63709 (RS / 4-03) ' � . �
� PtesvibcW Dy Department of Local Govemment Finance
INSTRUCTIONS: File Maric
To be (led in person or 6y mail with the County Auditor ot the county where the property is located. o� ,Q
Filing Dates: 1) Real Property: During the 12 months be(ore May 11 0/ the year the deduction is to 6e effect�ve. (/
2) Mobile Homes assessed under IC 6-1.1 J: Between January 15 and March 2 of the yeGt&�E��r�is ��T�ctive.
See reverse side for additional instructions and qualificaUons.
or contract buyer^ ee 2strictions on reverse side)
Taxing Disirid
Assessed value oi real property as
March i, current year
no, what is his / her exact share of interest?
Key �umber / legal description Record number
-S`��b
Page number
0 -608�$-�
MoRgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owner? �es ❑ No
3 ? DOd
If owned with someone other ihan spouse, indicate with whom.
If name on record is different than that ot applicant, indicate below:
of mortgagee or contract selier
Address of mortgagee or contraIX seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand street, city, state, ZIP code)
Does applicant own property in any other If yes, what counry?
county in Indiana?
Deduction approved in the amount of:
zo � I zo
certify under the penalty of
lent of Indiana and r e
Ke (owners !yl/r ame
What Taxing District?
Is the property in question:
❑ Mobile Home QC 61.7-n
Has this deduction been requested on
property for current yeaf? � Yes � No
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CC� 0..��• o'�I �
— Drawer N
2o�J i zo.
P
County Auditor
....
CardNO. •••••••••""""
Date
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ry that the above and foregoing information is true and corred and ihat the applicants was / were
aforementioned property on March 1, 20
Person authorized b�
or by IC 6-1.1-12-.07
applicant ' Q �n p(� p M� l� �� .. �Address of aulhorized person
of Attomey