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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
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� PrescriDed by Department of Local Govemment Finance "� � j,�' � ��
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INSTRUCTIONS: ,JUN Z$ ZOO4 File Mark
To be filed in person or by mail wfth the County Auditor of the county where fhe property is located.
Filing Dates: 1) Real Property: During the 12 months before May V o/ the year'the deduction is to 6e eflective7
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o/the yearthe deduction is to 6e elfective.
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See reverse side for additional instructions and qualifications. �i5S0'� c'n �r.(TV 4UDITC4
Applicant
Taxing Distrid
buyer-see
Assessed value of real property as of
March 1, wrrent year
If no, what is his / her exact share of interest?
Key number / legal
Rewrd number
DO � _ ��j/j3�� Page number
V�
MoAgage / ContreG indebtedness unpaid as of Is the ap�
March 1, current yeer o0 owneR
f.. �.i� 5��°
If name on record is different than that of applicant, indicate below:
of mortgagee or contract seller
Address of mortgagee or confract seller (number and street, city,
Name of assignee or other owner or holder of mortgage
Address of assignee (number and slreet, city, state, ZIP code)
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t the sole legal or equitable
❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
ZIP
Does applicanl own propeRy in any other � If yes, what county? I\^i'iat Taxing Distrid?
county in Indiana? ,
Deduction approved in the amount ot:
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Signature
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COUNTY AUDITOR
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County Auditor
Is lhe property in
❑ Real Property ❑ Mobile Home (IC 61.1
Has this deduction been requested on
property for wrrent yeaF?� Yes❑ No
zo
Date
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/ We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
� resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized b�
or by IC 6-1.7-12-.07
of authorized person