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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATtON Coun 7ownship Year
�' ��. ! SUte Fwm 637 W (RS l 4-03) '. : _ : : ' � , . � � . .. . . � ` \
� PresaiEeE by Department ol Loral Govemment Finance �
MAY 5 2004
INSTRUCTIONS: File Mark
To be filed in person or 6y mail with the County Auditor of the county where the property is located.� ��� n
Filing Dates: 1) Real Property: Dunng tfie 12 months 6efore May 11 of the year the deduction is to ;�ective. ��
2) Mo6ile Homes assessed under IC 6-1.7-7: Between January 15 and March 2 of tbe�yeeratte;dedoction�iseto�be�eHectroe.
See reverse side for addifional instructions and qualifications.
or contract buyer - see
Taxing DisiTfd ,
��,/2��
Assessed value of real property as of
March 1, current year
no, what is his / her exad share of interest?
reverse side)
Key number / legal
Record number
�� /� iy�,�, �� �"'a Page number a�a �
�C�C.P'C
Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current ye3r owner? ❑ Yes ❑ No
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If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
,ame of mortgagee or contracl seller /JC9!���
% %
—lll-.
Address of mortgagee or.contract seller (number and street, city, state.
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, Z!P code)
Does appliwnt own property in any ether I I; yes, vrhat counry?
county in Indiana? �
Deduction approved in the amount ot:
�
Signature
20 �
�
20 0 7
Vf
COUNTY AUI
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Couniy Auditor
Is the
❑ Real Properry ❑ Modle Home (IC 61.1
��� .••.••.• irequested on
DrawerNO........... ?n Yes❑No
`'a�a3
Card�}�1 yl ry � p• ��c�
Cx-cd,'���� �'IOmP
20�'� 20
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Date
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� We certify under the penalty of perjury �hat the above and foregoing information is [rue and corred and lhal lhe applicants was / were
resident of Indiana and owner of the aforementioned property on March i, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
(�t address of applicant IAddress of authorized person