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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 63709 (RS / 4-03)
Prescn�ed Cy Department ot Lorzl C.ivemment Finance
Coun Township Year
INSTRUCTIONS: File Maric
To be filed in person or 6y mail with the County Auditor of the counry whe2 the property is located.
Filing Dates: 1) Real Property: During the 12 montAs be%re May 11 of the year the deduction is to be eflective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ t eyreajrjthe dedu�c{tr'o-�n is to 6e eHective.
See reverse side for addifional instructions and quali�cations. ��j � ��
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Applicant (owner or ontpct�ee re 'cti ns on re erse side) N 0 V 0 2 2005
Ta�cing Distrid Key number / legal descri n Record numtier� ,Q� �
J
Q��30 bS G� Page numbe7•,"'" � �""' �•,
�a�
Assessed value ot real property as of � MoRgage / Conlrad indebtedness unpaid as of Is the applicant ihe sole legal or equitable
March t, current year March 1, current year owneR ❑ Yes ❑ No
1
If no, what is his / her exacl share of interesl? If owned with someone other than spouse, indicate wilh whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Horne QC 61.1-�
�me of moAgagee or contrad seller � �
Address of mortgagee or contrad seller (number and street, city, state, ZIP
. �.c�O.��l.GZ3
Name of assignee or other owner or holder of mortgage
Address of assignee (numbe� and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for current yea(?� Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
20� 20�� 20 0 ZO 20 20 20
� P
Signature County Auditor Date
�; We certify under the penalty of perjury that the above and foregoing infortnation is We and corred and thal ihe applicants was / were
r a resident of Indiana and owner of the af ementioned property on March 1, 20
Sign ure (o ers full nam Person authorized by duly executed Power of Attomey
. 'I
or by IC 6-1.1-12-.07
Ful sident address o plicant, • Address of authorized person
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