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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�� I State Form 63709 (RS / 4-03)
� PrescriDetl by Department ot Local Govemment Finarze p
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INSTRUCTIONS: File Mark
Tobe filed in person or by mail with the CountyAuditor of the county where the propeRy is located. �"�AR 2 g 2��4
Filing Dates: 1) Real Property: During fhe 12 months before May 11 0/ the year the deduction is to 6e effective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and MarcA 2 of th ear the deduction is to be e ctive.
See reverse side lor additional instructions and qualifications.
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Applicant(owne�orco c buyer-see
Taxing Dislrid
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Assessed vatue of real property as of
March 1, cuaent year
If no, what is his / her exact share of interest?
If name on record is different than that of
of mortgagee or contract seller
side)
Key riumber / legal
11- D%
Mortgage / Contrad inde
March 1, current year
of mortgagee or coniraIX selier (number and st2et,
Name of assignee or other owner or holder of mortgage
of assignee (num6erand st�eet,
Does applicant own property in any other I If
counry in Indiana?
Deduction approved in the amount of:
20
Signature
20 �
below:
J
Page number
ss unpaid as of I Is the applicant the sole legal or equitable
� owner? ❑ Yes ❑ No
% $,�
If owned with someone other lhan spouse, indicate with whom.
r
COUNTY AUDITOR
20 D I 20 �
1 �
County Aud'Rar
20
Slhe property in question:
❑ Real Property ❑ Mobile
61.
Has this deduction been requested on
property for current year? ❑ Yes❑ No
20
Date
3r]
We certify under the penalty of perjury that the above and foregoing information is true and corred and thal the applicants was / were
�efident�of Indiana and owner of the aforementioned property on March 1, 20
G1
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Address ofauthorized person