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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
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: �� / Sute Fwm 43709 (R5/4-03) �
Presaibed by Depanment of Local Govemment Finance
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APR 1 � 2003
INSTRUCTIONS: File Ma
To 6e filed in person or by mail with the Counry Auditor of the county where the propeRy is located.
Filing Dates: 1) Real PropeRy: Dunng the 12 months before May 11 of the year the deduction is to be,etl�stiv
2J Mobile Homes assessed under IC 6-1.1J: Between January 75 and March 2 o/tAe yearthe`deduc�ohlTsYtd,tl@'�ffecbve.
See reverse side for additional instructions and qualifrcations.
Applicant (owner or c ract 6uyer - see restn �on n reverse side) �
/�.
Taxing Distrid Key number / legal descrip on Record number
� �D� O/O �� _�(� Page number
Asse ed val e f real pro e y as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrrent year March 1, current year ownef? ❑ Yes ❑ No
(.(� �� �
If no, what is his / her exaci share of interest? If owned wilh someone other than spouse, indicate with whom.
If name on record is different than that ot applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-�
�me of mortgagee or contrad seller �/ � � C
cL
Address of mortgagee or contrect selier (number d street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this dedudion been requested on
county in Indiana? property for wrrent year? 0 Yes� No
COUNTY AUDITOR
Deduction approved in the amounl of:
2o zo D zo .Q(� zo � zo �� zo � zo
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Signature County Auditor Date
� We certify under the penalty of perjury that the above and foregoing information is lrue and corred and that the applicants was / were
:sidenl of Indiana and owner of the aforementioned property on March 1, 20
Signature I namg) Person authorized by duly executed Power of Attorney
ZF /�� ar by IC 6-1.1-12-.07
Full resident address of applicant Address of authorized person