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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS '
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S / State Fwm a3709 (RS I 4O3) ,-1
.«. -`i T
� Presai0e0 by Department of Lacal Govemment Finance � �i j}�
i i �� �
�NSrRUCnoNS: AUG 0 �ii�'0a3�
To be filed in person or by mail with the County Auditor o/ the county where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 months 6e%re May 11 of tbe year the deduction is to be eHec` e� (/./�� n
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0( t�e_year�the�deduch'�is to� effective.
See reverse side for additional insWctions and qualifications. � GI9SOiJ COUNTY d l�^iTO�
Taxing
Key number / legal desuiption ecord number
3•y3�b
Page number
/ C O -OOC�/ -co
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant t�h�e ole legal or equitable
March 1, curcent year March 1, current year ownef? L�Yes ❑ No
I 7353$ I
If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
name on record is diHerent than that of applicant, indicate below:
Is lhe property in
❑ Mobite Home QC Fr1.1-�
of mort agee or wntred seller �
� l'� � o-n, .
s of mortgagee or wntrad seller (number and sfreet, city, state, ZIP --- - __ __
Drawer NO...��
of assignee or other owner or holder of mortgage • • • • • • • • • • ..
Address of assignee (number and st2et, city, state. ZIP code) Ca rd N0. ... �.� 7Z%
n�y � �...........�...
Does applicant own property in any olher If yes, what county? What � a���u�r�� �� �u������ �__�� ��v�zsted on
county in Indiana? property for wrrent year? � Yes ❑ No
1/ l_. �, _ / l ✓ / ,�j,C./ / COUNTY AUDITOR
Deduclion approved in the amount of:
�
Signature
20
20 � 20 �
� County Auditor
� ��
20 �j_
('
20
' We certify under the penalty of perjury lhat lhe above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Full resident address of
1"eiDi .� I:..e.�l
V
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
person