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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES
= FOR DEDUCTION FROM ASSESSED VALUATION o �/ T �P Year
�• �w� ! State form 63709 (RS / 4-03) .
� PrescriDetl by Department of Loral Gdvemment Finarxe MAR S 2005
INSTRUCTIONS: � a,`°a'a�e Mark
To be (led in person or by mail wifA the County Auditor of the county where the property is loq�(@�pN COUNTY AUDITOR
Filing Dates: 1) Real Property: During the 12 months be(ore May 11 0/ the year the deduction is to 6e effective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0! the year the deduction is to be effective.
See reverse side /or additional instructions and qualifications.
Applicant. wn r tra uye - striction n 2 e side)
Tax' Disirid Key number / legal description Record number �
p� /�%�O[�j�� n� Pagenumber �
c� r ll T�� -z�
Assessed value of real prope as of Mortgage / Contrad indebtedness unpaid as of Is the appliqnt the sole legal or equitable
March 1, current year March 1, current year ownef? ❑ Yes ❑ No
Sooa
Ii 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 lhat of applicant, indicate below: Is the property in question:
i� � Real Property ❑ Mobile Hane pC Cr1.1-�
e of mortgagee or contrad seller /
Address of mortgagee or contracl seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sfreet, 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 20 20 (7� 20 20 20 20
� � P
Signature County Auditor Date
e certify under the penalty of perjury that the above and foregoing information is true and corred and thal the applicants was / were
sideni of Indiana and owner of the aforementioned property on March 1, 20
Signature ( w ers (u na e) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
I resident address of ap i nt � � Address of authorized person
D