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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
F�R DEDUCTION FROM ASSESSED VALUATION
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� PrescriDeO by Department of Loral Govemment Finance
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INSTRUCTIONS: ' f] (� M�
To be filed in person or by mail with the County Auditor of the county where the property is located.
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Filing Dates: 1J Real Property: Dunng the 12 months belore May 11 o/the year the deduction is to beQ,{��Ff iv .
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0! the ye�11He �d�cf�� to be elfective.
See reverse side for additional insWCtions and qualifications. ,_
buyer-see
Taxing District
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reverse
Key number / legal description I Record number
Page number
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Assessed value r al property as of Mortgage / ContraIX indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current y r March 1, current year owneR ❑ Yes ❑ No
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If no, what is his / her exact share of inlerest? Ii owned with someone other than spouse, indicate with whom.
If name on record is diHerent than that of applicant, indicate below: Is the property in queslion:
� ' � 0 Real Property ❑ Mobile Home (IC 61.1-�
/'ame of mortgagee or contrad seller �
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Address of mortgagee or contract seller (number and st�eet, city,
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sf�eet, city, state, ZIP code)
Does applipnt own property in any other I If yes, what county? i What Taxing District?
counry in Indiana? �
Deduction approved in the amounf
20
SignaWre
COUNTY AUDITOR
20 0� I 20 0� I 20 20
P P
County Auditor
Has this deduction been requested on
property for current year? � Yes ❑ No
20
Date
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We certi under the penalty of perjury that the above and foregoing information is true and correct and that lhe applicants was / were
eside of diana and owner of the aforementioned properfy on March t, 20
ur o ers full nam� Person authorized by duly executed Power of Aftomey
or by IC 6-1.1-12-.07
I e' t address of app' nt A _ ddress of authorized person
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