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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S �w� ! State Fwm 03709 (RS / a-03) ' . . . . .. . �
� PrescnEM by Oepartmeni of Loral Gtivemment Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor of the county, whe�e the property is located.
Filing Dates: 1) Real Property: During the 12 months be%re lNay 11 0/ the year the deduction is to be•eBective:
2J Mo6ile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 0/ th�ear t� d� ti� to 6e eflective.
See reverse side for additional instnictions and qualifications.
L..f'
(owner
Taxing Distrid
Assessed valu� of real property as of
March 1, current year
If no, what is his / her exact share
�j6ns on r rse side)
�
Key number! legal description
blq o�a�-�
Mortgage / Contrad indebtedness unpa
March 1, current year
If name on recnrd �� d�rta�=�� ��.�- ��-� of applicant, indicate betovr.
�ar ��W I � ��OY
Adc On (� ��n� �(number and street, c�
��d�
Nan �/ f y� p0 'der of mortgage
lC ��' i
Add '�lA-GyIC4J r7. CO�t, city. s;at=, ZlPcode)
Does applicant own property ir any other I If yes, •::hat couNy?
wunTy in Indiana?
Deduction approved in the amount of:
20 �� 20
� ,
Signature _
MAY 3 2004
0
Page number
as of I Is ihe applicant the sole legal or equitable
owner? ❑ Yes 0 No
If owned with someone olher than spouse, indicate with whom.
ZIP
Is the property in question:
❑ Real Properiy ❑ Mobile Home pC frt.
00(�-56y
1^lhat Ta:cing Distrid? Has this dedudion been requested on
property for current yea(?� Yes❑ No
COUNTY AUDITOR
20 �L 2Q Q
P P
Couniy Auditor
20 O h 20
�
Date
�
/ We certify under the penalty ot perjury that Ihe above and fcregoing information is true and correct and that the applicants was / were
I residenl of Indiana and owner of the aforemer.[ioned property on March i, 20
Person auihorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
un resftlent address of applicant Address of authorized person
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