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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Town1ship Year
' � «• J State Farm a3709 (R5/ a-03) . , � � , . � . . . � � � � �_��
� P25cnDed by Depanment of Local Govemmeni Finance J y�
..�
APR 3 0 2004
INSTRUCTIONS: File Mark
To be filed in person or 6y mail with the County Auditor o! the county where the property is located. //II n
Filing Dates 1) Real Property: During the 12 months be%re May 17 0/ the year the deduciion is to be eBe �„J ����
2J Mo6ile Homes assessed unde� IC 6-1. 7-7: Between January 15 and March 2 0/ the year the d�a8a"c?7on;is�to; be eflectiGe.
See reverse side for additional instructions and quali�cafions.
Applicant (owner or contract buyer- see restnctions on reverse side)
�
Taxing Dislrict Key number /Jegal descrip
4 �
� '" S�e'
Assessed value of real property as of Mortgage / Contrad indebted
March 1; wrrent year March 1, wrrent year
If no, what is his / her exact share of interest?
If name on record is different than that of applicanf, indicate below:
number
Page number
unpaid as of Is the applican t�sote legal or
owne(? es ❑ No
If owned with someone other than spouse, indicate with whom.
❑ Mobile Home (IC 61 J-�
of mortgagee or contred
,.. n _ .
or coniract seller (number and street, city, state. ZIP
Name of assignee or other owner or holder of mortgage `�
�
Drawer NO.� ••••••••
Address of assignee (numberand street, city, state, ZIP code) � '
ard NO. ....°Z.°��.�.......
Does applicant own property in any other � If yes, what counlj? �i�. •'p g ia5/�O OQ , been requested on
county in Indiana. I �7P" `ZT _�_.., ..,. ..,,��ent yea(?O YesO No
I -- ---- I I r.
COUNTY AUDITOR
Deduction approved in the amount oi:
20
Signature
20 �
20 D �
P
r� � i
County Auditor
20� 20
P
20
' We certi(y under the penalty of perjury that the above and foregoing intormation is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
name)
address of applicant
in/�i{rr�,l L.y
.1
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Person auihorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
authorized person