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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 437W (R4 / 10-01)
Prescnbed by Depanment of Local Govemment Pinance
INSTRUCTIONS:
To 6e filed in person or by mail with the County Auditor of the county where the property is located. � 9�oo�
Filing Dates: 1) Real Property: Dunng the 12 months be%2 May 71 0/ the year the deducfion is to be �1�Btiv .
2) Mo6ile Homes assessed under IC 6-1.1-7: Behveen January 15 and March 31 of the year the deduction is to be ef/ective.
See reverse side (or additional inst�uctions and qualifications.
l;IRRf1N C(1tINT1' 4UDITOR
Applicanl (ow or contiacf buyer- see restrictions on reverse side) �
Taxing Distnd Key number / legal desuiption Record number
I ��/'. w , �� � � � � DD / �(i'�,.\ Page number ���
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owneR ❑ Yes ❑ No
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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 than that of applicanl, indicate below: Is the property in question:
❑ Real Property ❑ Modle Hane (IC &1 _t-�
"'ame of mortgagee or contract seller
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Address of mortgagee or coniract seller (number and stieet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, sfate, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for current year? Q Yes � No
COUNTY AUDITOR
Deduction approved in the amouni of:
zo��(�-�n za�� zov Zo zo� zo zo Q �
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Si ature County Auditor Date
I� We certify under the penalty of perjury that the above and foregoing information is true and corred and that lhe applicants was / were
ident of Indiana and owner of lhe aforementioned property on March t, 20
Si ature (owner full name) Person authorized by duly executed Power of Attorney
or by IC 6-7.1-12-.07 '
I esident address of app icant Address of authorized person �
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