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- STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�> ._ / State Fortn a37W (RS / a-03) • �
Presaibed Dy Departmem of Local Govemment Finanm
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INSTRUCTIONS: � �
Coun Township Year
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To 6e �led in person or by mail with the County Auditor of the county where the property is located. -� 04
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to be ctive.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the y r he d on �o be ct"
See reverse side for additional insWctions and qualifications. Qf80QN q p�.
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Appl'cant ( ner or contract buy - see strict,ions o ersg side) ,
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Taxing Di trid Key number / legal description Record number Q
�1 r � �� _ �� - �(/ Page number �
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Assessed value of real property as of MoAgage! ContreU indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrrent year March 1, current year owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interest? owned wifh someone other than spouse, indicate with whom.
If name on record is different than lhat of applicant, indicate below: Is the property in question:
� ❑ Real Property p Mobile Home (IC Cr1.1-�
�ie of mortgagee or contraIX seller
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Address of morigagee or contrad selier (number and stie�
Drawer NO.. B.y.-.� � •• �'
Name of assignee or other owner or holder of mortgage _-
CardNO . .....................
Address of assignee (num6erand streef, city, state, ZIP cod �
Does applicant own property in any olher If yes, what counry? What Taxing District? Has this deduction been requested on
county in Indiana? property for current year?0 Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20�� 20 Q� 20 20 0 20 20 20
P Q
Signature County Auditor Date
e certiy under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
_�esid t of Indiana and er of th forementioned property on March 1, 20
Sign ur (ownels full n e Person authorized by duly executed Power of Attomey
� or by IC 6-1.1-12-.07
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Full res�dent address of applican� Address of authorized person
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