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� STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
;'' ' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�'• �«� ! Sute Fortn 43709 (RS / a-03)
� P25criDed �y Departrtrent of Local Govemment Finance
INSTRUCTIONS: File Maric
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1 J Real Property: During fhe 12 months be7ore May 11 0/ the year fhe deduction is{{{ggg......hhh��g���eee c ive.
2) Mobile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 of t,�ye�h dedu ion is�b effective.
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See reverse side for additional instructions and qualifications. g ��
(owner or
see restncnons o�erse sf )
Key number' lega desc
L./ �l�i.N-
UDITOR
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� ,fi / � _ O// C! //_ O � Page number� � n �
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Assessed value of real pr erty as of MoAgage / ContraU indebtedness unpaid as of Is the applicant ihe sole legal or equitable
March 1, currenl year March 1, current year owneR ❑ Yes ❑ No
0 0� d
If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different ihan that of applicant, indicate below:
��ne of mortgagee or contract seller
Address of mortgagee or conhact seller (number and st�e t, city, state,
assignee or olher owner or holder of mortgage
Address of assignee (num6er and st2et,
Does applicant own property in any
county in Indiana?
Deduction approved in the amount of:
20
Signature
20
state, ZIP code)
If yes, what county? I What Taxing Distrid?
COUNTY AUDITOR
20�_ 20 20
P P
County Auditor
❑ Mobile Home QC 61.1-�
Has this deduction been requested on
property for current year? � Yes� No
20
Date
20
certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
lent of Indiana and owner of the aforementioned propeRy on March 1, 20
ire (�wYne,ls(ull ie) Per� n authorized by duly executed Power of Attomey
j�T or b IC 6-1.1-12-.07
Full �sident address of applicant Address of authorized person
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