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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
: .�� / St3te Fortn 03709 (R5/ 4-03) _
�� PfesfnDeO by Department of Local Govemment Finance
IN�TRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor o! the county where the property is located. APR 1$ 2��5
Filing Dates: 1) Real Property: Dunng the 12 months be%re May 11 0/ the year the deduction is to 6e eflective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0! the year`tl�eductjq� to be effective.
o'�as.1 .cs
See reverse side for additional ins[ructions and qualifications. O(BSON COUNTY
_ AUDITOR
Applicant
Taxing
[9
Assessed value of real property as of
March i, current year
If no, what is his / her exact share of interest?
name on record is difterent than lhat
� � - of mortgagee or contrad
of mortgagee or contrad seller
on rever,v� side)
Key number 1 legal description Record number Q�
�j9 /Yl y�/ � Page number
/ �iC/ /
Mortgage / Contrad indebtedness unpaid as of Is ihe applicant the so e legal or
March 1, wrrent year owneR ❑ Yes ❑ No
0 �'v0 �
� If owned with someone other than spouse, indicate with whom.
it, indicate below:
//
and street, "ty, state, ZIP
of assignee or other owner or holder of moAgage
Address of assignee (num6er and st2et, city, state, ZIP code)
Does applicant own property in any other I If yes, what county?
county in Indiana?
Deduclion approved in the amount of:
20
Signature
20
couNrr auon
20 � 20 Q 20
P
County Auditor
Is the property
❑ Real Property ❑ Mobile Home QC 6-1.1-�
� , Drawer�NO. :°. �..�..'�.......
Card NO. ....�..�5. � .......
flc�; ����g3 �O
20
20
:ted on
�s❑ No
��� certify under the penalty of perjury that the above and foregoing informalion is true and correcl and that the applicants was / were
jent of Indiana and owner of the aforementioned property on March 1, 20
name)/_ , —�
9 01'�-�7�'
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
� a�5�5�'��� Address of authorized person
c-�v('f�.fik-�_, M `�71i7i)