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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VAIUATION tyy vq Tow p Year
" / State Form 63709 (RS I 4�3) 0�
Prascribed by DepartrtieM of Lacal Govemment Finance �
N V 1 2005
INSTRUCTIONS: File Mark
To 6e filed in person or by mail with the County Auditor o( the county whe2 the property is located. �
Filing Dates: 1) Real Property: Dunng the 12 mon[bs be%re May 11 of tAe year the deduction is to 6e eHec �ve.'� �
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o/the y�'ai�?Tie�t/�dQclfo7�Ys,�y�gff�ctive.
See reverse side /or additional instrucfions and qual�cations.
Applicant (o r or contract buyer - see restndions on rev�e side)
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Ta�cing Distrid Key number / legal escription Record number
I,�q � jl� _ OQ�/_ � /^ O ��' ` Page number �
K���•I IQ� l.J V l:.J CX)
Assessed value of real property a of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, cunent year MarcFi 1, wrrent year g� O t.13 O� owner? ❑ Yes ❑ No
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l Q Q!
Ii no, whal is his / her exact share of interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is different than tliaf oi applicant, indicate below: Is the property in question:
� Real Property ❑ Mobile Home (IC 61.1-�
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me of mortgagee or contract seller ��
Address of mortgagee or cont�ad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and stieet, city, state, ZIP code)
Does applipnt own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for current yea(? � Yes❑ No
COUNTY AUDITOR
Dedudion approved in ihe amount of:
20 20 O� 20 20 20 20 20
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Signature County Auditor Dale
W certiy under the penalty of perjury that the above and foregoing information is true and corred and lhat ihe applicants was / were
�-a r ident of Indiana and owner of lhe aforementioned property on March 1, 20
' n re (owners (ull name) _ Person authorized by duty executed Power of Attomey
�� W' or by IC 6-1.1-12-.07
u si ent ress of �pliqnt Address of authorized person
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