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iei "� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
t\�� FOR DEDUCTION FROM ASSESSED VALUATION Township Year
—`�J+ State Form 63709 (R6 / 5-06) - •
� M Presaibed by Department of Local Gwemment Finance
OCT 2 5 2007
INSTRUCTIONS: File Mark
To be liled in person or by mail with lhe CountyAuditor ot the county where the property is located. �/ �
Filing Dates: 1) Real Property: Dunng the 12 months before June Il of the year the deduction is to be e((ective�
2) Mo6ile Homes assessed unde� lC 6-1.1-7: Between January 15 and March 2 of th��tltEqtip���effective.
See �everse side fo� addifional instructions and qualifications.
ApplicaM (owneror contract 6uyer - see restrictions o 2verse side) � C�:vv�"K
,�c.,2-G�a�»-� 4�
Tax�ryg Districf Key number / legal desaiption Record number
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�'/a -0'I-303 -O0�• pagenumber
�; � -0�8 S � 9 0
Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, curtent year owneR ❑ Yes ❑ No
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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 diifereni ihan that of applicant, indicate below: Is the property in question:
O Real Properiy ❑ M�ile Home QC 61.1-�
me of mortgagee or contrad selier •
Address of moRgagee or contrad seller (number and s ieet, city, state, ZIP
Name of assignee or other owner or holder of mortgage �,a/h �"�
W
Dra�ver•NO......
Address of assignee (num6erand street, city, state, ZIP code) �Sy'O .
Doesa licantown ro e �O•
pp p p rty in any other If yes, what county? What Tax Card �11y�� ryys. � d on
county in Indiana? ,_. ,,,,��e�n yeanLl Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
20�� 20 O 9 20 20 20 20 20
�
Signature County Auditor Date
�We certify under the penalty of perjury that the above and foregoing informalion is true and corred and lhat lhe applicants was / were
residenl of Indiana and owner of lhe aforementioned property on March t, 20
Sign re (owne/s full n ) Person authorized by duty executed Power of Attomey
� ' or by IC 6-1.1-12-.07
FuII resi ent address of applicant Address of authorized person
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