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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
" FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S. ✓ Slate Fwm a37�9 (RS / 4-03) � -
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� Prescnbed by Department of Local Gtivemment Finance •
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INSTRUCTIONS: .SCP � z,e4�'^�1804
To 6e (led in person or by mail with the CountyAuditor of the county whe�e the property is located.
Fi/ing Dates: 1) Real Property: During the 12 months be(ore May 11 0/ the year the deduction is to be e"ifective. / /�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 75 and March 2 0/ the year the dedaction is,to be e�ecNv'e.
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See reverse side for additional instructions and qualifications. _— �� GL°.SO" """"�" "'
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Applicanl (o er or con 2ct buyer- see restrictions on reve.
Ta�cing District Key number / legal description Record number O
\�.�.L. ��z�-� �,cC�T ��d - d�CJ 7��- U V Page number
Assessed value of real propeAy as of Mortgage / Contract indebtedness unpaid as of is the appli t the sole lega or equitable
March 1, curcent year March 1, current year owne(? ❑ Yes ❑ No
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Ii no, whal 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 applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home QC 61.1-�
�me of mortgagee or contrad seller � /�
Address of mortgagee or contracl seller (number and st2et, y, state, ZIP
Name of assignee or other owner or holder of mortgage
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Address of assignee (number and street, ciry, state, ZIP code)
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Does applic (�� � What Taxing Distrid. Has this deduction been requested on
county in Inc Dra�yep NO.i��?:. �, property for current year?O Yes� No
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S���ardNO....C�.l��,.�... ��.pUDITOR
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Deduction a Cc��� J� �� ��
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Signature County Auditor Date
'� We certify under the penalty of peryury that the above and foregoing informalion is true and corred and lhat the applicants was / were
�esident of Indiana and owner of the aforementioned property on March 1, 20
Signat re (owners full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Ful resident address of applicant Address of authorized person
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