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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 63709 (RS / a-03)
PfescnDed by Departmem of Local Govemment Finance
Coun Township Year
�INSTRUCTIONS: File Mark
To be filed in person or by mail with the CountyAuditor of the county where the propeRy is located.
Filing Dates: 1) Real Property: During the 12 months be%re May 11 of the year [he deduction is to b e ve
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ tbe . fh�de�� �0 6� ctive.
See reverse side for addiUonal instructions and qualiFca[ions.
(owner o�
Taxin istrict
�W� � �
Assessed value of real
March 1, curtent year
as of
no, what is his / her exact share of interest?
on
�
number / legal description
OCT 16 2003
/i� O � Q�/ G��O Page number ��
LI �f
Mortgage / Contract indebtedne�s unpaid as of Is the applicanf the'sole legal or equitable
March 1, current year �� °,LOQ O. owner? ❑ Yes ❑ No
�.000 o �
If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate
of mortgagee or contract seller
Address of mortgagee or contrad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street,
Does applicant own property in any
county in Indiana?
Deduction approved in the amount of:
20
Signature
zo 05
�
state,
If yes, what county? � What Taxing District?
20 QC�
�
COUNTY AUDITOR
� _:J
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Counry Audiror
20 __Q�
s the property in
❑ Real Properly ❑ Mobile Home (IC Cr7.
Has this deduction been requested on
property for current year? ❑ Yes � No
20 �L 20
1
Date
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 1, 20
(owner's
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
person