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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Ye�
��w� J State Fortn 63709 (R5/ 4-03)
� Presai�ed by Department of Local Gdvemment Finance
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INSTRUCTIONS: � � J,;.,J 1iFile'Mark
To be filed in person or by mail with the County Auditor of the county where the property"�s located.
Filing Dates: i) Real Property: During the 12 months before May 11 of the year the deduction i �to �be aflecfLv,�3
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0( the year the deduction is to 6e effective.
See reverse side for additional instructions and qualifrcations. �(J
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/'1 _ � r-��SON CJ.� :- . . ����-C°. I
Applicanl
Disirict
Assesked value of(ieal properry
March 1, wrrenl year
see
no, what is his / her exact share of interesl?
If name on record is different lhan lhal
of mortgagee or contraIX
Address of mortgagee or contract seller
Name of assignee or
Address of assignee (number and street,
side)
Key number / legal description
W J—v
Mortgage / ContraG
March t,�trrenta�e:
i��
....
Record number ^�
d ✓^
Page number
Is the applirant the le legal or equitable
owneR Yes ❑ No
If owned with someone other than spouse, indicate with whom.
d, indicate below:
�
and street, ci , state, ZIP /
state,
s�th//e p�eperty in questian:
LJ�Real Property ❑ Modle Horne (IC 61.1-�
- � �� Drawer NO....lJ.:3;-;�3%7
, _� . -
Card NO . ...:...........
') ......
Does applicant own property in any olher I If yes, what county? I VJhat Taxing uisina�!
county in Indiana?
i ir �v .�v oc —L-/
Deduction approved in the amount of:
20� 20
�"7A B0�
Signature
COUNTY AUDITOR
20 (L 20
�
County Auditor
20 ��
na� uua ueuuwvn �ccn �cyuwted on
property for current yeaR � Yes ❑ No
20 � 20
�
Date
certiy under the penalty of peryury that the above and foregoing information is true and coned and that the applicants was / were
IeM o(indiana and owner of the aforementioned property on March 1, 20
ners lull name) Person authorized by duly execuled Power of Attorney
_ (�n � � j� n n ,� � or by IC 6-1.1-12-.07
of authorized person