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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Ye:
. w� / Stata Fwm <3709 (RS / 4-03)
,� PtespiDeE by Department of Local Govemmeni Financa —
INSTRUCTIONS: � FI �Fil�ark�
To be filed in person or 6y mail with the County Auditor of the county where the property is located�� }i y`—
Filing Dates: 1J Real Property: During the 12 mon[hs 6efore May 11 oI tbe year the deduction is to be eflective. ��} 2003
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year tii'e�deduction is to be elfective.
See reverse side /or additional instructions and qualifications. �� /� /J �
Applicant (owner o�q cf buyer - see
Yr
Taxing Distrid
\�i�1�i wW � �
Assessed value of real property as of
March 1, current year
If no, what is his / her exact share of interest?
If name on record is
side)
Key number / legal description
Vv�
MoAgage / Contract ir
March 1, current year
lhat of applicant, indicate below:
moAgagee or contrad setier
. v'
Record
� Page number �O �
unpaid as of Is the applicant the sole egal or equitable
ownef? ❑ Yes ❑ No
If owned with someone other fhan spouse, indicale with whom.
Address ot mortgagee or contrad seller (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, sfate, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District?
county in Indiana?
Deduction approved in the amounf
20
Signature
�
COUNTY AUDITOR
20 20 � 20
� P
County Auditor
Is the property in question:
❑ Real Property ❑ Mobile Home QC 61.1-�
Has lhis deduction been requested on
property for current yea(? � Yes � No
20 Q`L 20
P
Date
' We certify under the penaity of perjury that the above and foregoing infortnation is We and corred and that the applicants was ! were
resideni o( Indiana and owner of the aforementioned property on March 1, 20
� re (o�vners full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
r�dent a�es� ppli fit_ �� // i ^ ^ �A�r�s of a�horized person
f\ OC � �/7, L3if��7i1 �7