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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
: � �� / Siate Fwm 63709 (R5 / 4-03) ' .
� PrescriDeE by Department ol Lofal Govemment Finance �� �' j; �� �
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wsrRUCrioNS: APR �+e M��4 �'�
To 6e filed in person or by mail with the County Auditor o) the county where the property is located. �'
Filing Dates: 1) Real Property: Dunng the 12 months be%re May 11 0/ the year the deduciion is to b�effective. �
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2J Mo6ile Homes assessed under IC 6-1.1J: Between January 15 and March 2 of the'yea,the; dedGotion is to be.effeytive.
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See reverse side for additional instructions and qual�cations. __
Applican (owner or confract buyer- see restrictions on reverse side) .�,
Taxing Disirid Key number / legal description Rewrd numbe
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Page number � � n
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owneR ❑ Yes ❑ No
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 that of applicanl, indicate below: Is the property in question:
❑ Real Properly ❑ Mobile Home (IC 61.1-�
�ame of mortgagee or contrect seiler
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Address of mortgagee or contraIX seller (number and s6eet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this dedudion been requested on
county in Indiana? property for wrtent yeaR� Yes� No
COUNTY AUDITOR
Deduction approved in the amounf of:
20 �,� 20 20 �`� 20 20 � 20 20
P � P
Signature County Auditor Date
��/ We certify under the penaity of perjury that the above and foregoing infortnation is true and corred and that lhe applicants was / were
reside f Indiana and owner of the aforementioned property on March 1, 20 �
Si re (owners /ull name) Person authorized by duly exewted Power of Attomey
' or by IC 6-1.1-12-.07
ull resident address of app cant Address of authorized person
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