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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownshi Year
�> � ♦ State Fwm 63709 (R514-03)
'� PresaiDed by Department of Local Gevemment Finance
To bef ed�'noperson or by mail with the CountyAuditor of the counry where the property is loca e� �� Fite Mark
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to be ¢Hective.
2) Mobile Homes assessed under IC 6-1.1-7: 8etween January 15 and March 2 o/the yegr�A�e �'g�'c�p/i�� to 6e eNective.
See reverse side /or addifional instructions and qualifications.
Applicant (owne� or contract
Distrid
Assessed value of real property as of
March t, current year
on
Key number / I I description
�/o -/8_ 3 _ YaF -Cno.i37- A09
� � d �3-t�i37-�c7
MoAgage / Contrad indebtedness unpaid as
March 1, current year
/.3�.0 oa .
If no, what is his / her exact share of interest?
If name on record is different than that of appliwnt,
of mortgagee or contrect seller
--'---' --���.
below:
��^� � �
�""' `-��ry y AUDITOR
Record number � �
Page number � S 9
O
Is the applicant the sole legal or
ownerT ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
city, state, ZIP
Drawer i\TUpwQ7 —.�5�—
Namei w•••••••••• ,
Addres Card i\'� . ........:............ ocode)
� ry��,/�
Does� ���3%�jW. �d :ounty?
county in maiana r �
Dedudion approved in fhe amount of:
20 Y0 �_ 20 �
P P �
SignaWre
s the property in
❑ Real Propaty ❑ Mobile Hane OC 61.1-
What Taxing Dislrid? Has lhis dedudion been requested on
propeAy for curtent yeafl0 YesO No
COUNTY AUDITOR
20
County Aud'Aor
20
20
20
certify under the penalty of perjury that the above and foregoing information is lrue and corred and ihat the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
Person aulhorized b�
or by IC G1.1-12-.07
executed Power ot Atromey
of authorized person