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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Siate Fortn a37os (R4 / lo-oi)
Prescribetl by Deparimenl of Local Govemment Finance
INSTRUCTIONS: � q File A� �
To be filed in person or by mail wilh the County Auditor ol the counly wheie the property is located. g
Filing Dates: 1 J Real Property: During the 12 months belo2 May 11 0l the year the deduction is to be effecti��� ���^��
2) Mobile Homes assessed under IC 61.1-7: Between January 15 and March 31 of the year th u � �1 e effective.
See reverse side /or additional instructions and qualifications.
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Applicant(o ' orcontractbuyer-se�stn�tiQ��revers� '
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Ta�cing District Key number / legal description Record number ��
' Page number
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole lega or equitable
March 1, wrrent year March 1�rrent year ownef? ❑ Yes ❑ No
7000�
If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate wilh whom.
If name on record is different than that of applicanl, indicate below: Is the property in question:
❑ Real Pmperiy � Mobile Hmie pC 6-1.1-'�
�y�ame of mortgagee or contract seiler ��
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Address of moAgagee or contrad seller (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st�eet, city, state, ZIP code)
Does applicant own property in any other Ii yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for curtent year? � Yes❑ No
COUNTY AUDITOR
Dedudion approved in the amount of:
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Sign ture County Auditor Date
I/ 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 7, 20
ignatu`e owners full na Person authorized by duly execuled Power of Attomey
� ���� or by IC 6-1.1-12-.07
ull resident address of applicant � Address of aulhorized person
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