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� STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS �
FOR DEDUCTION FROM ASSESSED VALUATION Cou n ip Year
�s «� �/ State Form 63709 (RS / 6-03) . .
� Prestnbed by Depariment Of lo[al Govemment Finance �Q� � V ZOO6
INSTRUCTIONS: �� ��y�
To be �Ied in person or by mail with the County Auditor o/ the county where the property is Iocat�lggON C�UN7Y q DITOR
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is to be ef/ecfive.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year tAe deduction is to be ef/ective.
See reverse side for additional instructions and qualiTcations.
buyer-
Taxing DisVid
�Wi�RO/LJ'C-K/�
Assessed value of real property as of
MarcFi 1, current year
side)
Key number / legal description
O/%Qo���'-��.
Mortgage / ContraU indebtedness unpaid as
March 1, current year
Record number
Page number O � a
f Is lhe applicant ihe sole legal or equitabie
ownef? ❑ Yes � No
If no, what is his / her exact share of interesl? '� If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicanl, indicate below: Is the property in queslion:
❑ Reai PropeAy ❑ Mobiie Home (IC 61.
�e of mortgagee or contract seiler �/� ,
Address of mortgagee or contrad seller (nu er and street, city, state, ZIP �
Name of assignee or other owner or holder of mortgage TM � --
Dra�ver NO ....:........
of assignee (number and street, city, state, ZIP code) •••••
Does applicant own property in any other If yes, what counry? Card N�.V ;�Q�j',,,-l0(p� judion been requested on
county in Indiana? � current year? � Yes� No
COUNTY AUDITOR
Deduc6on approved �n the amount of: '
20
Signature
20 Op'
20�20 20
�
County Auditor
20
Date
20
certify under the penalty of perjury lhat the above and foregoing information is true and corred and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
� or by IC 6-1.1-12-.07
resident address of applicant � �Address of authorized person