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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�. � J Sute Fwm a3709 (RS / 4-03) �� g �
� P25cdDed Ey Depetlrtrent of Loral Govamment Finance LJ
INSTRUCTIONS: S E P F�e �a�006
To be filed in person or by mail with the County Auditor ol the county where the propeKy is located.
Filing Dafes: 1) Real Property: During the 12 months 6e(ore May 11 0/ the year the deduction is to be effectiye. a� ,G��
2J Mobile Homes assessed under lC 6-1.1-7: Between January 15 and March 2 o(the YeGIB50rei cUUN7v ��U�i�p�ctive.
See reverse side for additional instn�ctions and quali�cations.
^YY��w� �� l�rvnm �, wnuac� uuyer - see resrncuons on reverse side)
• �� . .
Taxing Distrid Key number / legal description Record number
c►�-/7G/-�aSrGY�O•L/� a�� O C�
� Page number
� o�'l - aa (�►Z-op 5 J
Assessed value of real property as of Mortgage / Contraci indebledness unpaid as of Is the applican t�sole legal or equitable
March 1, current year March 1, current year owne(� es ❑ No
If no, what is his / her exact snare of interest?
If name on record is difterent lhan that of applicanl, indicate
of moAgagee or contraIX selier
a o ozx�
If owned with someone other than spouse, indicate with whom.
of mortgagee or contrad seller (number and street, city, state, ZIP
assignee or other owner or holder of mortgage
of assignee (numberand st2et, city, state, ZIP
property in questian:
al Property ❑ Mobile Home pC 61.
Does applicant own property in any other I( yes, what county? What Taxing District? Has this dedudion been.remiested on
county in Indiana? _ -- — ' '
� �. �7 Yes❑No
_ Drawer NO.• � �5`��
,
COUNTY AUDII �
Deduction approved in the amount
20 _QZ
Signature
20
20 �_ 20 _
1
County Auditor
CardNO . .....................
Date
certify under the penalty of perjury that the above and foregoing information is true and corred and ihat the applicants was / were
ent of Indiana and owner of the aforementioned propeAy on March 1, 20
applicant
Person authorized by duly executed Power of Aftomey
or by IC 6-1.1-12-.07
of