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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION C ry Township Year
/, S / State Fwm 437W (R5 / 6-03) F' �t11
'(� Prescnbe0 by Department of Lotal Govemment Finance A,� �j 4. �
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�RUCTIONS: /-� �File NTdfK
i be filed in person or 6y mail with the County Auditor of [he counry where the property is /ocate��
Filing Dates: 1) Real Property: Dunng fhe 72 mon[hs before May 11 0/ fhe year the deduction is,t e eHective�
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2) Mobile Homes assessed under IC 6-1.1-7: Behveen January 15 and March 2 of the year-the daduUion is'to be ejtactive.
' aUDITOR �
See reverse side for additional instructions and qualifications.
(owner or contract
0
Taxing District
Assessed value of real property as of
March 1,cunentyear
If no, what is his / her exact share of interest?
on reverse
0
Key ur ber / legal description I Record n�mber 3
Page number
6 �l
Mortgage / Contract indebtedness unpaid as of Is the applican�e sole legal or equitable
March 1, curzent year owner? Yes ❑ No
�
If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
Name of mortgagee or contract seller
or contract seller (number and street, city,
Name of assignee or other owner or hoider of mortgage
sfreet, ciry, state, ZIP code)
Does applirant own property in any other If yes, what county?
county in Indiana?
20
Signature
approved in the amount of:
20
��
>a-�. a�3 -E
Is the property in question:
�eal Property ❑ Mobile
E1.
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Wh ��� .n requested on
� fl�L�/ _ _ ar? ❑ Yes ❑ No
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COUNTY AUDITOR
20 20 0� 20 ��
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Counly Auditor
20 0 9
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Date
20
I/ We certiry under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was I were
a resident of Indiana and owner of the aforementioned property on March 1, 20
�nature (owners (ull name) Person authorized by duly executed Power ot Attomey
, o'_ b. y n� �rPn.,., � or by IC 6-1.1-12-.07
resident�addre s of appiicant Address of authorized person
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