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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
`r i F FOR DEDUCTION FROM ASSESSED VALUATION
�`:�� ! State Fwm 63709 (RS / a-03)
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PresaiDed Gy Oepartment of Laal Govemment Finance
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INSTRUCTIONS:
To be (led in person or by mail with the County Auditor of the county whe�e the propeRy is located.
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is to be e/(ective.SEP 0 8 2003
2) Mobile Homes assessed under IC 6• 1.1 J: Behveen January 15 and March 2 0/ the year the deduction is to 6e effective.
See reverse side for additional instructions and qualifications.
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Applicant
i axing Dislrid
Assessed value o( real property as of
March 1, wrrent year
If no, what is his / her exact share of interesl?
If name on record is differeni than that
mortgagee or contrad seiler
of mortgagee or contrad seller
tions on reverse side)
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Key number / leg I description
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Mortgage / Co—nt�� ct indebledness unpaid as
March 1, current year
Name of assignee or other owner or holder of mortgage
.lddress of assignee (number and street, city, state, ZIP code)
number
Page number
is me appucan[ e soie iegai or
owner? es ❑ No
If owned with someone other than spouse, indicate with whom.
Does applicanf own property in any other I( yes, what county? I What Ta�
county in Indiana?
Deduction approved in the amount
1 r -�I�j'�1
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Signature
COUNTY AUDITOR
2�
County Auditor
❑ Mobile Hame (IC 61.1
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Drawer N0.o3-. �f'�''�'
Card NO . .....................
' � ' ' iesled on
�� -r�� �r �vr current year? L� Yes 0 No
20 �_ I 20
1
Date
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I/ We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
��sident of Indiana and owner of the aforementioned property on March t, 20
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
of apblicant U v" 1 I Address of authorized person
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