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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNE
FOR DEDUCTION FROM ASSESSED VALUATION � oun 7ownship Year
�. ' -! Staze Fom: <3709 (RS / 6-03)
� p
. PresaiDetl Uy Dapanment ol Loral Govemment Finance
8 2005
INSTRUCTIONS: File Mark
To be filed in'person or by. mail with the County Auditor ot the county whe�e the propeRy is loca���„ �
Filing Dates: 7) Real Property: Dunng the 12 months be%2 May 11 01 the year the de��},s� tp 6e e//ecr �.
2) Mobile Homesassessed under IC 6-1.1-7: Between January 15 and March 2 o�ltlfe`}�e�sr'(he�gduvcl�'on is to be eHecfive.
See reverse side for edditional instructions and qualifications.
Applicant (o� r or contract buyer - see resfn�ctions�verse side)
JiIL2-4�YL-CR �
Taxing Distrid Key number / legal description
UO -GG _ %"
Record number
Page number
�. i
Assessed value of real property as of MoRgage / Contract indebtedness unpaid as of Is the applicant the sole legal or i
March 1, current year March 1, wrrent year owner? �.Yes ❑ No
Qd ��
It no, what is his / her exact share of inierest? If owned with someone other than spouse, indicate with whom.
If name on record is different than lhat of applicant, indicate below: Is the propeAy in question:
of mortgagee or contract seller �
/
Address of mortgagee or contract seller (number and street, city, stale, Z!P
Name ot assignee or otfier owner or holder of mortgage
Address of assignee (numberand street, city, state, ZIP code) �
Does applicant own property in any other I If yes, what county? Wh�
county in Indiana?
Deduction approved in the amount of:
�
Signature
20
�
couNrv au
20 �� 20 20
P
County Auditor
❑ Mobile Home QC E1.1-
Drawer NO..�J,�,-;S`}, 90
Card NO. `�
�
Date
20
ested on
YesO No
We certify under the penalty of perjury that the above and foregoing infortnation is true and correcl and thal lhe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
name) � .
applicant
� �' 28
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person