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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
'� FOR DEDUCTION FROM ASSESSED VALUATION
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P25rnbetl by Depanmeni of local Govemment Financa
Coun Township Year
INSTRUCTIONS: File Mark
To be filed in person or 6y mail with the CountyAuditor of the county where the propeRy is located. (VilaR 1 4 2��%
Filing Dates: f) Real Property: During the 12 mon[hs be%re May 11 0/ the year the deduction is to be etfective.
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MoAgage / Conlrad indebtedness unpaid as of Is the appli
March 1, current year owner?
If name on record is different ihan ihat of applicanl, indicate below:
mortgagee or coniraIX
( �OS�
t the sole legal or equitable
❑ Yes ❑ No
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owned with someone olher than spouse, indicate with whom.
Address of mortgagee or conVad seller (number and sfieet, city, state,
Name of assignee or other owner or holder of mortgage
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Address
Does applicant ow
courity in Indiana?
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Deduction approved in the amount of:
20 20 O Zp �
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Signature
What Taxing District?
COUNTY AUDITOR
20 20
County Auditor
Is the
❑ Real Properly ❑ Mobile Home QC E1.1-
Has this deduction been requested on
property for current year? � Yes � No
20
Date
20
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
(owne�s full
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Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
���o��� a�,��css u� ap ucam - Address of authorized person
dI� E. dN St' . _ _ _ . _ .