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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�' FOR DEDUCTION FROM ASSESSED VALUATION Coun I Townshi Year
` Sute Fwm a3709 (R5/4-03) � �` � k� � � � �� �
� Prescri0ed by Departmem ol Local Gtivemment Finance �3 Fi i/
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�^ 0 C f� S 2004
INSTRUCTIONS: , File Mark
To be Fled in person or by mail with the County Auditor o/ the county where the property is locat �d / �� �%
Filing Dates: 1) Real Property: During the 12 months 6e%re May 11 of the year the deduction isltQ-be e/Iecfive��,��.G
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of-fhe;y_ear, tir�eideduction;is7o 6�ffective.
See reverse side Ior additional instructions and qualifications.
Applicant (ownerorcontract 6uyer- see st�ns on reverse side) �
. �C
Taxing Distrid Key num er lega� description Record number
� G � - �"S
b ( 6 _ �Q � 6 � — �G Page number
Assessed value of real property as of Mortgage / ContraG indebtedness unpaid as of is the applicant the sole legal or equitable
March t, wrrenf year March 1, current year ownef? ❑ Yes ❑ No
/03oU� '
If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in quastion:
-� ❑ Real Property ❑ Mobile Home QC Fr1.1-�
�'�,me of mortgagee or contract seller � --�
Jv Drawer NO.. �?L � l,L�- 0� —
Address ot mortgagee or contrad seller (nu .'• ••.... „.. S
Cardi\'p,..,'^�i. ' _ .
Name ot assignee or other owner or hoide� � . ,� _
Address of assignee (number and st2et, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for current year? �] Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
20 2 20 ��' 20 �_ 20 20 20
P � �
Signature County Auditor Dale
I We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
sident of Indiana and owner of the aforementioned property on March 1, 20
Si na�e (ownefs (u� e)„n Person authorized by duly execuled Power of Attomey
� � or by IC 6-1.1-12-.07
full resi�en '�e�� f applica � Address of authorized person
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