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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
''• / State Form 63709 (RS / 6-03)
�«
� Prespibed by Department of Local Govemment Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor of fhe county whe2 the property is located.
Filing Dafes: 1) Real Property: During the 12 montbs 6efore May 11 0/ the year the deduction is to be efiective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Maich 2 of the year the deduction is to be ef(ective.
See reverse side for additional instructions and qualifications.
Applicant
Taxing Distrid
- see
Assessed vatue of real property as of
March t, current year
Ii no, what is his / her exact share of interest?
name on record is different lhan that of
of mortgagee or contraIX seller
side)
Key number / legal description Record number
�
� _ � O— � Page number � Y
1 �
Mortgage / Contra indebledness unpaid as of �s the applipn the sole legal or f
Marcp�Furrenl year owneR es ❑ No
cp�i
a c�a
/ If own d with someo other than spouse, indicate with whom.
`�'Y1 a�-� (�.• 0 3- bes 7
d� -9 �
ant, indicate below: Is the orooertv in auestion:
Address of mortgagee or contrad seller (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
of assignee (numberand st2ef, ciry, sfate,
Does applicant own property in any other If yes, what county?
county in Indiana?
20
!�
Signature
approved in the amount of:
20�r
What Taxing Di:•
COUNTY AUDITOR
20 Q(a 20 � 20 �
B� P �
County Auditor
G7-S.11
Home (IC Gt.
Drawer NO.��:..��7�'...
Card NO . .....................
20 � 20
Date
We certify under the penalty of perjury lhat lhe above and foregoing information is true and correct and that the applicants was / were
resident of Indiana and owner of lhe aforementioned property on March 1, 20
�nature (owner (u/I n e) Person authorized by duly executed Power of Attomey
�a �_�� �j� J or by IC 6-1.1-12-.07 �,
of authorized person
0