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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
`' 1� FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S�.,w� / S�ate Fwm a3709 (R5/ a-03)
� PresaiDed by DepaRment of Loral Govemment Finance
INSTRUCTIONS: - � - " - - File�Mark -
To be filed in person or by mail witb the County Auditor of fhe county where the property is located.'j'""� �� � f� �
Filing Dates: i) Real Property: Dunng lhe 72 months before May 11 0/ the year the deduction is to be e/fective� �
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year fhe deduction is to be enective.
See reverse side for additional instructions and quali�cations.
SEN i 2 2003
Applicant (owner or contract
Taxing Disirici
r.
Key number / legal tlesuiption - � Record number
AsSessed value o(�al property as of � Mortgage / Contrect
March 1, currentdfar March 1, current e�
If no, what is his / her exact share of interest?
Ii name on record is different than that of applicant, indicate below:
ot mortgagee or contrad seiler
Address of mortgagee or contract seller (number and street, city,
Name of assignee or other owner or holder of mortgage
of assignee (numberand st2et, city, sfate, ZIP code)
.�.-�,:n��=-.- .
x �
O�Q ,� U Page number a�
'6
ndebtedness unpaid as of Is the applicant the sole legal or equitable
r owneR ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
s the property in question:
❑ Real Property ❑ Mobile Home QC 61.
Does applicant own property in any other I If yes, what counry? I What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for curtent year? � Yes� No
Deduction approved in the amounl of:
20
Signature
COUNTY AUDITOR
20 aCD I 20 h`% I 20 ��
County Auditor
20 D�i � 20
Date
20
We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
�esident of Indiana and owner of the aforementioned property on March t, 20
(owners (uJl�ame) .
����
address oi applicant
��3aa�
Person authorized by duly execuled Power of Attorney
or by IC 6-1.1-12-.07
� Address ofauthorized person
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