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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S / Sqte Fortn 63709 (RS / d-03)
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� P25criEed by Department ol Local Govemment Finance
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INSTRUCTIONS: yp-�' File-Ma�!$ •�
To be �led in person or by mail with the CountyAuditor of tAe county where the property is IocateQ` ���J l;�
Filing Dates: 1) Real Property: During the 12 months before May 11 01 the year the deduciion is to be eflecfivei�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the ye�r l��d9tlucti�d� to be effective.
See reverse side for additional instnictions and quali�cations.
licant (ownerorcontract 6uyer- se�strictions on rev e side� ""'''
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Taxi District Key num er I al description Record number
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/\ 1 n_ O��� � Page number
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Assessed value of real property as of Mo gage / Contract indebtedness unpaid as of Is the applicant the/�ole legal or equitable
March 1, wrrent year March 1, current year owneR �1'es ❑ No
if no, what is his / her exact share of interest?
If owned wifh someone olher than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
Name of mortgagee or contrad seller 5�.
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Address of mortgagee or contract seller ( mber and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
of assignee (number and sfieet, city, state, ZIP code)
Does applicant own property in any other If yes, what county? I What Taxing
county in Indiana?
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Signature
approved in the amount of:
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COUNTY AUDITOR
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County Auditor
in question:
❑ Mobile Hmie QC Gt.
Drawer NO .::................
Card NO. ��.., /���
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propeny ror w��e��� y«, :.� .__.� No
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Date
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/ We certify under the penalty of perjury lhat the above and foregoing information is true and corred and that the applicants was / were
1resident of Indiana and owner of the aforementioned property on March 1, 20
(owners full name)
Person authorized by duty executed Power of Attomey
or by IC 6-1.1-12-.07
of applicant �Address of authorized person