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� STATENiENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�• t State Fwrt: 43709 (R5 / 4-03I
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PrescriDed by �epartment of Local Govamment Finance
Coun Township Year
AUG 1 S 2005
INSTRUCTIONS: File Maric
To be filed in person or 6y mail with the Counry Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months be%re May 11 01 the year the deduction is to 6e e/% �
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2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the YGIBSONd� t'� i ective.
See reverse side for additional instructions and qualifications.
Applicant (o n r or cont�act buyer - ee
.i �i1 n �/oi � /
i axing u�stna // Key number / legal description Record number ��
� �/ ^
O�� _�� � 3— y,l� Page number /
Assessed value oi real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, wrrent year owner? ❑ Yes ❑ No
�� Ol1U
if no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
I( name on record is
mortgaqee or contrad seller
applicanf, indicale below:
❑ Real Property ❑ Mobile Home (IC Cr1.1-�
0
Address of mortgagee or contract seller (number and street, dty, state, ZIP
Nart
Add
Do�
coi'
De
2
Signature
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C.N �
1��,� �p,�
O -T v-a .o .. �,
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ode)
inty? What Taxing Dislrict? Has this deduction been requested on
property for current year? �] Yes � No
COUNTY AUDITOR
20
County Auditor
�
20
20
We certify under the penalty of perjury lhat the above and foregoing information is true and correct and that the applicants was / were
resident of Indiana and owner of the atorementioned property on March 1, 20
�na (owners Iull na ) Person authorized by duty executed Power of Attomey
I��� � �� ��/ or by IC 6-t.t-12-.07
resident add�esgbf a9plicant Address of authorized persan
.30�0 .�. �%i'ne ��, f�rQh�. !�,_ 5�2G �s�