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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownshi Year
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� P2scriDed �y Department of local Gtivemment Finance
� E C 3 0 2004
INSTRUCTIONS: File Ma
To 6e filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During fhe 12 months belore May 11 0( the year the deduction is to be 'v
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 olthe r({�831Btli2tMtt �`to'��ti e.
See reverse side for additional instructions and qualifications.
Applicant (owne�orc t yer- see restrictions o e erse side)
Taxing Dislrid Key number / I I description Rewrd number
_ F/ �r �} Page number �
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant ihe sole legal or equltable
March 1, currenl year March 1, current year ownef.� (� es ❑ No
/ �
If no, what is his / her exacl share of interest? Ii owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is t property in question:
Real Property � Mobile Home (IC 61.1-�
�me of mortga e or cont sellq�( „ �
/ °1
Address of mortgagee or contract seller (number a st , city, stafe, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, cify, state, ZIP code)
Does appiiwnt own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for wrcent year?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 J�� 20 � 20 � 20 20 20 20
� P � ,�
Signature County Auditor Date
� We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
Signalure (owners full name) Person authorized by duly executed Power of Attomey
��� a, or by IC 6-1.1-12-.07
uil resident address of applicant Address of authorized person