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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS —
FOR DEDUCTION FROM ASSESSED VALUATION Cou .,-rt7ownship y`{�Year
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Prescnpetl by Departmeni of Local Govemmem Finance }L
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INSTRUCTIONS: File Mark
To be (led in person or by mail with the County Auditor of the counry where the property is located. `�j7a� ,a��.
Fiiing Oates: 1) Real Property: Dunng the 12 months before May 11 o/the year the deduction is to be eflective. �� �^ TY pUD�TpR
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ tAe year tf��deQdction is�o be eltective.
See reverse side ior additional instructions and qualificatrons.
Applicant (owner o� contract b yer - see resMctions on �ever�e �iC�)
/ /
Taxing Dislrid Key mber / legal desuiption Record number ��
,' /� o o s-o, 9i a-� Page number
Assessed value oi real propeAy as of Mortgage / Contract indebtedness unpaid as ot Is the applicant the sole legal or equitable
March 1, curtent year March 1, current year ownef? [�es ❑ No
0 �
If no, what is his / her exact 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 the property in question:
�ime o( mortgagee or wnitact seller _ ��0�1' � Mobite Home (IC 61.1-�
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Address of mortgagee or contrad seller (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sVeet, city, sfate, ZIP code)
Does applicant own propeAy in any olher If yes, what counry? What Taxing District? Has this dedudion been requested on
county in �ndiana? property for current year?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
zo �� zo �J � zo 0'' 2o zo zo 20
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Signature County Auditor Date
� We certify under the penalty of pe ' ry that the above and toregoing information is true and corred and that the applicants was / were
� a resident of Indiana and owner of t forementioned property on March 1, 20
ignature n s full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
II resident address of ap cant Address of authorized person