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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
:. / State Fwm a37W (RS / 4-03) � � � � �
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� Prescribed by Department of Local Govemmenl Finance
'� MAR 3 �
INSTRUCTIONS: F����
To be filed in person or by mail witA the CountyAUditor of the county where the property is located
Filing Dates: 1) Real Property: During the 12 months be7ore May 11 0/ the year the deduction is � e el%ctivE � ��
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o/t e[gf�e`'�uc_ 95't ective.
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See reverse side for additional instructions and quali�cations.
Applicant(ywn rorcontracfbuyer-
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Key
reverse
Record number
�g���� Page number � � C
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Assessed value of real property a of Mortgage / ContraG indebte�ness unpaid as of Is the appli nt the sole legal or E
March 1, current year March 1, current year � 3� ��c�..q_ owne(? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned wifh someone other than spouse, indicate with whom.
If name o� record is different than that of applicant, indicate below: Is the property in question:
■ •-. • .� ■
of mortgagee or contract seller
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y � CL.�
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Address of mortgagee or contraG seller (num er and st2et, city, state, ZIP '
c�-�c� o� - ti sa5
Name of assignee or other owner or holder oi mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applipnt own property in any other If yes, what county? What Taxino��"
county in Indiana? ' rj�
�ra„ et
COUNTYAUDII Card��•
Deduction approved in the amounl
20 �� 20 G (o
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Signature _
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County Auditor
20 �
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Date
�. � / „ �sled on
•.��� ��� es�No
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We ceAify under the penalty of peryury that the above and foregoing infortnation is lrue and corred and that ihe applicants was / were
resident of Indiana and oy�er of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Address ofauthorized person