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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Townsnip Year
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�«� Presdibed Ey Department of Local Govemment Finance ��� ��� � I7 ,\
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INSTRUCTIONS: /,�U(j i b ����a�
To be �led in person or 6y mail witA the County Auditor of the counry where the property is located.
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deductionl,s•to 6e effective. i i
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 ot_lhe year the deduction is to b�eflective.
See reverse side for additional instructions and qualifications.
�'� GI9SGt� C�U �T� CR
Applicant
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Assessed value of real property as of
March 1, current year
if no, whal is his / her exact share of interest?
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IS�vinumber / legal description Record number
U�/ %- t� �
(„�/��a ��U Pagenumber �O
MoRgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year ownefl ❑ Yes ❑ No
If name on record is different than that of applicanl, indicate below:
�e oi mortgagee or contrad seller n_ /, ^ a-
/ / / Lf
If owned with someone other lhan spouse, indicate with whom.
Address of mortgagee or wntract selier (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
(number and sfreet, ciry, state, ZIP code)
Does applicant own property in any other I If yes, what county?
county in indiana?
Dedudion approved in the amount of:
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Signature
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Is the property in queslion:
❑ Real Property ❑ Mobile Home pC 61
What Ta "�'-�eduction been requested on
Dr �—°4_� Yes❑ No
a wer N�.'Q.,� `
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couNrv au�r ard �'�. . . �
20 G� 20 �� 20 '1U_
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County Auditor
certify under the penalty of peryury that the above and foregoing informalion is true and correct and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
u ners (ull name) � Person authorized by duly executed Power of Attomey
t�.j A�,��� , n����L o� by IC 6-1.1-12-.07
fesident address of applicant " Address of authorized person
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