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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
(�. ! Siate Form a3709 R514-03 � J {{{ I � �
�«• ( � � ` � f � � \
� PreSaiDed Oy Departmeni ot Local Gtivemment Finance ll j,J ��J ��
° St�' 2 2 2004
INSTRUCTIONS: Fil�ark
To be (iled in person or by mail with the County Auditor o/ the county where the property is located. �
Filing Dates: 1J Real Property: Dudng the 12 months be(ore May 11 0/ the year the deduction is to�be<ettecti�J �� �� �
2J Mo6ile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 0/ the yeaFthe'deduction is. to be•effective.
See reverse side for additional instn�ctions and qualifications.
con(ract
Taxing Dislrid
�(.C���Q ��
Assessed value of real property
March 1, wrrent year
see restnc6o,�5 on
Key number / legal description
��� • �l�U %—U 0
of MoAgage / Contrad ir
March 1, current year
s�.a�°�
If no, what is his / her exaci share of
name on record is different than
oi moAgagee or contract selier
of applicant, indicate below:
Nart
Chhst-i►.c�, �
Addi �
S�ther a►�
cour
J'� UUU . Ou
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Dedi ���� ��
zo t Z o u�{ -(�r 3 I �
`t - � - o`�
s�9�
as
number �O
Page number
Is the applicant the sole legal or equitable
owneR ❑ Yes ❑ No
If owned wilh someone other than spouse, indicale with whom.
ZIP
What Taxing District?
TY AUDITOR
Q9. zo
P
s the property in ques6on:
❑ Real Properiy O Mobile Home QC 67.
Has this dedudion been requested on
property for wrrent year? � Yes ❑ No
20
zo
certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicanls was / were
ient of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power
or by IC 6-1.1-12-.07
person