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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 437 W(RS / 4-03)
Prescribed by Depanment of Local Govemment Finance
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INSTRUCTIONS: � � I ��p �a (003
To be filed in person or by mail with the Counry Auditor of the county wAere the propeRy is located. 1
Filing Dafes: 1) Real Property: During the 12 months 6efore May 11 of the year the deduction is to 6e el7ective. /�
2J Mo6ile Homes assessed under IC 6-1.1-7: 8etween January 15 and March 2 0/ the yea the deducti n i�tb 6e e ctiv
See 2verse side lor additional instnrctions and qualifications. �SOt�N Y AUDITOR
Applicanl (owner or contract 6uyer - see restrictions on reverse side) �
Taxing Dislrict K y number / legal description Record numb
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Page number
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Assessed value of real property as of Mortgage / Contrad inde tedness unpaid as of Is the applicant the sole legal or equitable
March t, cunent 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 olher than spouse, indicate with whom.
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If name on record is difierent than that of applicant, indicate below: Is lhe property in queslion:
❑ Real Property ❑ Mobiie Home (IC 61.1-�
�e of moAgagee or contrad seller
Address of mortgagee or contraIX seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage Drawer NO ...............
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Address of assignee (numberand st�eet, city, state, ZIP code) Card NO. . ��� S~ �. �"-�
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Does applicant own propeAy in any other If yes, what county? auested on
counfy in Indiana? r.,.,_.., .__ _ ] Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 � 20 O(L 20 20 �� 20 �_ 20
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Signature County Auditor Date
�/ We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and lhat the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners (ull name Person authorized by duly executed Power of Attomey
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Ful esident address of applicant Address of aulhorized person
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