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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
State Form a37os (Ra i taot�
PresrxiDed Dy DepaNreN of Local Govemment Finan[e ?r
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INSTRUCTIONS: File Mark
To be filed in person or by mail wifh the County Auditor o/ the county whe�e the property is locate�i t l� 1 � Z�03
Filing Dates: 1) Real Property: During the 12 months be%re May 11 of the year the deduction is to 6e effective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and Marcb�. 31 0l the�the� e�doctipn�'to be eflective.
See ieverse side for additional instructions and qualifications. 5��"�� « -L �
Giasora Co:1NTY AUDI �OP. .
Appli nt (ovme�orcontra f buyer- see �estrictions on reverse side)
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Taxing Distrid Key number / I descriplion Record nu e� 3_� O�j �/
/��� LV'/�-t.( �/ OV v�Q 3/��— QQ� Page number
Assessed value of real property a of MoRgage / Cantred indebtedness unpaid as of Is the appliwnt 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? 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 (IC Cr1.1-�
�ame of moRgagee or conlrad seller �
Address of mortgagee or wntrad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand sGeet, city, state, ZIP code)
Does applicanl own property in any other If yes, what county? What Taxing District? Has this dedudion been requested on
county in Indiana? property (or current yeaR� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount oi:
20 Q,�'� 20 20 D� 20 [Z� 20 20 20
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Signature County Auditor Date
1/ We certify under lhe penalty of perjury lhat the abave and foregoing infortnation is true and corred and ihat the applicants was ! were
resident of Indiana and owne e aforementioned property on March 1, 20
Signal er a ) Person authorized by duly executed Power oi Attomey
or by IC 6-1.1-12-.07
ull residen ddress of apptipnl Address of authorized person
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