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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
,+ «� ♦ State Fwm a37W (RS / 4-03) . .
� Prescribetl by DepaRment of Lotal Govemment Finance � � u� �
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INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor of the county wheie the property is located. �U N 0 5 2��6
Filing Dates: 1) Real Property: During the 12 monfhs 6efore May 11 of the year the deduction is to be eflective.
2) Mobile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 of the year the deduction is to 6e ef/ective.
See reverse side for additional instructions and qualifications.
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„ � rIFiSON COUNTY AUDITOR
Distrid
Assessed value of real
March 1, current year
of
no, what is his / her exact share of
Key number /
Record
� /��� � � Q(� ' � Page number
Mortgage / ContraG indebledness unpaid as of Is lhe ap�
March 1, curr t ear � ownef?
� c��,bDa
If name on record is different lhan that of applicanl, indicate
of moRgagee or contrect seller
Address of mortgagee o� contrad selier (number and street,
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand slreet, city, state, ZIP
t the sole I�o�quitable
❑ Yes ❑ No
If owned wilh someone other than spouse, indicate with whom.
state, ZIP
Does applicant own property in any other If yes, what county? � What Taxing District?
county in Indiana?
—//`� — COUNTY AUDITOR
De � �
2� �
S�� �o�a - � � �
20
dy Auditor
20
Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.
Has lhis deduction been requested on
propeAy for current yea(? � Yes� No
�
Date
20
We certify under the penalty of perjury that the above and foregoing information is true and corred and that ihe applicants was / were
�esident of Indiana and owner of the aforemenlioned propeRy on March 1, 20
name)
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
ss orappucant Address ofaulhorized person
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