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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION un w' Year
�� w� / State Form 4370g (RS / 4-03)
� PrestnbgE yy Department of Local Govemmenl Finance FEB 1 2 2007
INSTRUCTIONS: ��7j6-.���
To be filed in person or 6y mail with the County Auditor oJ the county whe�e the property is located. G�BgON COUNTY AUDITOR
Filing Dates: 1) Real Property: During the 12 months be%re May 11 of the year the deduction is to be eflective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is to be eNective.
See reverse side lor additional instructions and qualifications. •
6uyer-see
Taxing Dis
I
Assessed value of real property as of
March 1, currenl year
Ii no, what is his / her exact share of inleresl?
Key nu er / legal description Record numb
a�-� -�q-�o�-000, �9i-o.,-6
�j� —OO ��� � Page number
MoRgage / Contrad indebtedness unpaid as of Is the ap�
March 1, current year / nM owner?
i h�� ��(0�7W
0%
t the sole legal or equitable
❑ Yes ❑ No
If owned with someone other lhan spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
'me of mortgagee or contrad seller ��
Address of mortgagee or contrad selier (number and stieet, city, state, ZIP
Name of assignee or other owner or holder of moAgage
Address of assignee (number and sGeet, city, state. ZIP code)
Does applipnt own property in any-other If yes, what county?
county in Indiana? �
Deduction approved in the amount of:
20 �Z 20 Q�_ 20 �_
P �
Signature
Is the pr
❑ Real
m
� Mobile Home pC 6-1.1-n
�
p� W �.....
WhatTaxin� �C3���CY��•••••..••••
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C�rd;O...•� 1a�,9�� —
COUNTY AUDITOR
20
Counry Auditor
20
�
Date
20
�n
No
We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
�esident of Indiana and owner of the aforementioned property on March 1, 20
(owners /ull
FUII resident address of applicant / y
��03 S. LJ�.�.�� �• Z/� �/�i�cl, c� y7L
. �—�--------------
Person authorized by duiy executed Power
or by IC 6-1.1-12-.07
of authorized person