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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS -- --�—� '�
' FOR OEDUCTION FROM ASSESSED VALUATION Couh '; i Townshi 1 Year
�•d� _ "- ! State Fwm 637p9 (R5 / 6-03) � � � �.i �J
� Presaip¢p py Department of Loral Govemment Finance
n r 3 005
INSTRUCTIOIJS: File-Mark
To be filed in. person or by mail with the County Auditor of the county where the properfy is located. �6`� N y�
Filing Dates: 1) Real Property: During the 12 months be%re May 17 o/fhe yearthe deduction is to be.e�ecti,ve�p�N7Y AUDITOR
2J Mo6ile Homes assessed under IC 6-1.1-7: 8etween January 15 and March 2 0l the yea�rlhe deduction is to be effective.
See reverse side /or additional instructions and quali�cations.
Applicant
Taxing
Assessed value of real property as of
March 1, currenl year
:ti�� on rse side) �� /I ���
/
Key number / legal description
c� � a - oo�g9 ob
MoRgage / Contract indebtedness unpaid as
March 1, current year
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Record number �
Page number � ,�
Is the applicant the sole legal or
ownef? ❑ Yes ❑ No
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 different than fhat of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home QC fr1.
�me of mortgagee or contraU seiler
Address of mortgagee or contract seller (number and streef. �i(y, state, ZIP
assignee or other owner or holder of
of assignee (number and street, city, sfate, ZIP code)
Does applicant own�property in any other I( yes, what county? 4Vhat Taxing Distrid?
counry in Indiana?
Deduction approved in the amount of:
20 / �
Signature
20 ��
9
COUNTY AUDITOR
20 � 20 20
�
Counry Auditor
Has this deduction been requested on
property for current year? � Yes � No
20
Date
20
certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attorney
or by IC 6-7.1-72-.07
ay�honzed person
/ L/