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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
" ' FOR DEDUCTION FROM ASSESSED VALUATION �3 Coun Township Year
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Prescri0ed Dy Department of Local Govemment Fina�
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INSTRUCTIONS: � A P RF�� �'a�O3
To be filed in person or by mail with the County Auditor oI the county where the property is focated.
Filing Dates: 1) Rea/ Property: During the 12 months belo2 May 11 of the year the deductlon is to be� Ie/fective. �
2) Mo6ile Homes assessed under IC 61.1-7: Between January 15 and Maich 31 0/ the year the dedut���� !$ to be ef(ectnive.
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See reverse side loradditional instructions and quali�caGons. � GI3SON COUP:?v •r,tJD;TOR
Applicant (owner or contract b�yer- see restridions on reverse side)
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Taxing District Key number / legal description Record number
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Assessed value of real property as of MoAgage / Cantrad indebtedness unpaid as of Is the applican t� he sole legal or equitable
March 1, current year March 1, current year ownefl �� es ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
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If name on record is different than that of applicant, indicate betow: Is the property in question:
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'ame of moRgagee or contrad seller •
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Address of mortg gee or contred -s-e�lle^r (number and st2e city, state, ZIP
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Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, sfate, ZIP code)
Dces applicant own property in any olher If yes, what county? What Tauing Distrid? Has this dedudion been requested on
county in Indiana? property for wrrent year? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amounl af:
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Signature County AudRor Date
�I/ We certify under the penalty of peryury that the above and foregoing infortnation is lrue and corred and thal lhe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners !u!1 name) Person authorized by duly execuled Power of Attomey
w or by IC 6-1.1-12-.07
Full resident address of applicant Address of authorized person
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