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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
' FOR.DEDUCTION FROM ASSESSED VALUATION Coun Township Year
N� �:I State'Fwm 43709 (R5 / 4-03)
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� Presaibed by Department of local Govemment Finance
irosrRUCnoNS: JUN 2 7 �005
ile Mark
To 6e filed in person or by mail with ihe County Auditor of the county where the property is located.
Filing Dafes: 1) Real Property: Dunng fhe 12 months 6efore May 11 0l the year the deduciion is fo 6e��f�c�e ��
.�� 2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of th�Sy�������c����be e�fective.
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See reverse side for additional instructions and qualifications.
Applicant (ownerorco cf yer- see res rict' v e side) ' �_ _ a(�
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Tax' trid Key number / legal descriptio Recor number ��
- G y a�� -� Page number �/� /�
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Ass ssed value of real property as Mortgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1; current year �� March 1, current year owner? ❑ Yes ❑ No
_ 5 QoO
If no, what is his / her exact shaie of interest? If owned with someone other than spouse, indicate with whom.
If name on record is Cifferent than thal of applicant, indicate below: Is the property in question:
� � - � . ❑ Real Property ❑ Modle Hortie (IC 61.1-�
�:me of mortgagee or contract seller �
Address ot moRgagee or contrad seller (number and str t, city, state, ZIP
Name ot assignee or other owner or holder of mortgage
Rddress of assignee (numtier and street, city, state, ZIP code)
Does applicant own property in any other I( yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? � �� property for current year?� YesO No
COUNTY AUDITOR
Deduction approved.in the amount of:
zo � zo oy 20 � za 2o zo zo
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Signature County Auditor Date
�! We certify�under the penalty of perjury that the above and foregoing information is true and corred and that lhe applicants was / were
a,resident of Indiana and owner of the aforementioned property on March 1, 20
r(owners full a ) Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
Full resident address of applicant � Address of authorized person