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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun o ship e
+ ! State Fortn 63709 (RS / 4-03)
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� PrescnUeO Dy Depanment of Loral Govemment Finance
INSTRUCTIONS: e Mark �
To be �Ied in person or 6y mail witA the Counry Auditor o! the counry where the property is located. aU�
Filing Dates: 1) Real Property: During the 12 months befo2 May 11 0/ the year the deduction is to be effecti�y O CO N�� ITOR
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0l the year the �dSuc�on is�{o�e �ect�ve.
See reverse side lor additional instiuctions and qualifications.
buyer-
Taxing Disirid
Assessed value of real property as of
March 1, currenl year
on
Key number / legal description
Mortgage / Contract ii
March 1, current year
Record
Page number
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�ss unpaid as of Is the applicant the sole legal or
ownef? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned wilh someone other than spouse, indicate with whom.
a�-� -� - o�- �. ags-aac�
If name on record is different lhan that of applicant, indicate below: Is the properiy in question:
mortgagee or conlrad seller
of mortgagee or contrad seller (number and sf2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
(numberand street, ciiy, state, ZIP code)
Does applicant own property in any other If yes, what county? What Tauing Distrid?
county in Indiana?
� y_ �� y-,/ /J� _ L/� ii// COUNTY AUDITOR
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Signature
in lhe amounf of:
20 � 20�_
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Couniy Auditor
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❑ Mabile Horne pC 61.1
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Has this dedudion been requested on
property for current yeaf? � YesO No
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Date
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certify under the penalty of perjury lhat the above and foregoing information is true and corred and that the applicants was l were
ieni of Indiana and owner of the aforementioned property on March 1, 20
(owners full
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
�S+aencaaaress or�ppuwnt Address of authorized person
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