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STATEAAENT OF MORTGAGE OR CONTRACT INDEBTEDNES�
� FOR DEDUCTION FROM ASSESSED VALUATION
�. �� ' ! State Form a37W (RS / 4-03)
Prescri�ed Gy Department of Local Govemment Finance
��IlJSTRUCTIONS:
To be filed rn person or by mail with the County Auditor of !he county where the property is
Filing Dates: 1) Real Property: During the 12 months before May il o) the year the deduction is to� �I/eeti�e.9003
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the ar tiie de7uction is to be effective.
See 2verse side lor additional instnrctions and qualifrcations. /� � � /� n
Applicant
Dislrid
6uyer-
Assessed value of real property as of
March 1, current year
If no, what is his / her exacl share of interesl?
l�I
March t
side)
/ legal descriplion ( J � Record
— �77 —O� Page number S
/ Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
�ent year owner? ❑ Yes ❑ No
����
If owned with someone olher than spouse, indicate with whom.
If name on record is diHerenl than that of applicant, indicate below:
�ame of mortgagee or conirect seller (`��
�ddress of moAgagee or contract seller (number an treet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand street, city, state, ZIP code)
Does applicant own property in any other If yes, what county?
county in Indiana?
Deduction approved in the amount of:
20 I/�'1 _ 71 20
What Taxing Distrid?
COUNTY AUDITOR
20
County Auditor
❑ Real Property ❑ Mobile Home (IC 61.1-�
Has this deduction been requested on
property for curtent year? � Yes � No
20 �� 20 �_
� �
Date
20
I/ We certify under the penalty of perjury that the above and foregoing information is true and corred and lhal the applicants was / were
'resident of Indiana and owner of the aforementioned property on March 1, 20
i�ure (owners /ull name) Person authorized by duty executed Power of Attorney
i1 _ _ _ / –'� �__ / or by IC 6-1.1-12-.07
t address of applicanl - Address of authorized person
43 C/teSi //GIG� /��