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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES�
FOR DEDUCTION FROM ASSESSED VALUATION
State Pwm 637W (RS / 4-03)
Presaibetl by Department of Loral Govemment Finance
INSTRUCTlONS:
To 6e filed in person or by mail with the County Auditor o/ the county where the property is
Filing Dates: 1) Real Property: During the 12 montbs 6efore May 11 o/the year the deduction is to b4��f�cl�L� 2��3
2) Mo6ile Homes assessed under IC 6-1.1-7: Belween January 15 and March 2 0/ the year fhe dedur�tion
See reverse side for additional instructions and qualifications.
Applicant (owner or
Assessed value of real property as
March 1, current year
if no,
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is to
Key number! legal description Record number � 2
ol
�!_ _ O/ 2 ( ()� � Page number
e7 I _.J J 6 (j
MoRgage / Contrad indebtedness unpaid as of Is lhe applicant the ole legal or
March 1, current year �c�l�`'' owner? ❑ Yes ❑ No
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If owned with someone other than spouse, i�dicate with whom.
Drawer NO ................••• �nt, indicate be�ow:
03_ �0��..
Card NO . .............. � / „
city, state, ZIP
of assignee or other owner or holder of mortgage
of assignee (num6er and sf�eef, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid?
county in Indiana?
Deduction approved in the amount of:
20 // 7 I 20
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COUNTY AUDITOR
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County Auditor
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Is the praperty
❑ Real Property ❑ Mobile Home (IC 61.1
Has this dedudion been requested on
property for current year? � Yes ❑ No
20 �_ 20
P
Date
/ We certify under lhe penalty of perjury lhat the above and foregoing information is lrue and corred and lhal ihe appiicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
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Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
person