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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
� FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
: J Stata Fwm 43709 (RS / 4-03) ' .
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� PresaibeE by Department of Local Govemment Finance
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INSTRUCTIONS: n File Mark
To be /iled in person or by mail with the County Auditor o) the county where the property is located. U E C � � 2��3
Filing Dates: 1) Real Property: Dunng fhe 12 months before May 11 of the year the deduction is to be eflective. �
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Ma�ch 2 0/ the year the deduction is to be eNective.
See reverse side for additional instructions and qualifications. �"'""'�-�"�'�L! +^� =� -� ���,_ �
GI6SC�ra C(,Jr:l r ;,;;�;7�n {
Applicant (owner
Taxing Distrid
Assessed value ofYes
March 1, curzent year
of
If no, what is his / her exact share of
Key number / legal description
D O .�00 S 70 -�
Record number
Page
3�f
Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year / O Q�� ownef? ❑ Yes ❑ No
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name on record is different ihan that of appliwnt, indicate below:
of moAgagee or contrad seller
of mortgagee or conlrad seller (number anit�t�eet, city,
Name of assignee or other owner or holder of mortgage
of assignee (num6er and street, city, state, ZIP code)
own property in any other � If yes, whal wunty?
county in Indiana?
Deduction approved in the amount of:
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Signature
owned with someone other than spouse, indicate with whom.
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WhatTaxing Disfrid?
Drawer NO.�.z:-...3.Y...
Card \'O . .....................
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County Auditor
Is the property
❑ Real Properry ❑ Mobile Home
Has this deduction been requested on
property for current yeaR� Yes❑ No
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p
Date
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' We certiy under the penalty of peryury that the above and foregoing infortnation is true and corred and that ihe applicants was / were
residenl of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners
Person authorized by
or by IC 6-1.1-12-.07
of applicant �Address of authorized person
of