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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�. «� / State Forrt; 637W (RS I 4-03)
PresaiDed by Department of Laal Gtivemment Finance
� �� '� —; „'—� �� .
INSTRUCTIONS: � � � File Mark�
To be filed in person or by mail with the County Auditor of the counfy where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 months before May 11 of the year the deduction is to 6e elfect1ve: (�(�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o(the yearihe de'd�'f�iS� is to be elfective.
See reverse side Ior additional instructions and qualifrcations. � /� n n
(owner
see
Assessed value of reai propArty as of
March 1, wrrent year
If no, what is his / her exact share of interest?
If name on record is different lhan lFiat
of mortgagee or contrad
/ legal description \ I Record number O
O /��� b Page number y O� ^�
O}
Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal o quita'
March 1 ent year ��'�I �� owneR �es ❑ No
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If owned with someone other than spouse, indicale with whom.
ant, indicate below: Is lhe property in question:
, �}7Real Pioperty ❑ Mobile Home pC 61.'
Address of mortgagee or contract seller (number
Name of assignee or other owner or holder oi mortgage
Address of assignee (numberand street,
Dces applicant own propeRy in any
county in Indiana?
Deduction approved in the amount of:
20 y�l�
city, state, ZIP
sfate, ZIP code)
If yes, what county? � What Tauing District?
COUNTY AUDITOR
20 � I 20 ULa 20 �� 20
P
County Auditor
Has this dedudion been requested on
property for wrrenl year?� Yes� No
20 0 l 20
P
Date
We certify under the penalry of perjury that the above and foregoing information is true and corred and lhat the applicants was / were
residenl of Indiana and owner of the aforementioned property on March 1, 20
�,nature//fowners (ull name) �D n, � n, Person authorized by duty executed Power of Attomey
"1i "Id � . . _ �.J. �,.. J. �+r�.,.L�A.�� v� orbylC6-1.1-12-.07
applicant - Address of authorized person
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