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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
SUte Fwm d37p9 (RS / 4-03)
PrescriEed by Department of Local Govemment Finante
Coun Township Year
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INSTRUCTIONS: File Mark
7o be filed in person or by mail with the County Auditor of the county where the property is located. {{� � Q� 2��4
Filing Dates: 1) Real Property: Dunng the 12 months 6efore May 11 0/ the year the deduction is to be eflective.
2J Mo6ile Homes assessed under IC 6-1.1-7: 8etween January 15 and March 2 of the yea tr he deduction is to 6e ef/f/ective�
See reverse side for additional instructions and qualifications. ��-(-��-�� J��� ^-�-{�.�
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Applicant (o e or contract buyer - see r�strictions r verse side)
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Taxing Distri Key number / lega� de iption Record number Q
Q1��� �/// Q � I/� � D � Page number
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Assessed value of real property as of Mortgage / ContraG indebtedness unpaid as of Is the applicant the sole I gal or equitable
March 1, wrcent year March 1, current year owner? ❑ Yes ❑ No.
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different Ihan lhat of applicant, indicate below: Is the property in question:
� Real Property p Mobile Home QC Cr1.1-�
��ne of mortgagee or contrad seller �
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Address of mortgagee or contract seiler (number and st2et, city, state, ZIP �
Name of assignee or olher owner or holder oi mortgage
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Address of assignee (num6erand street, city, state, ZIP code)
Does appliwnt own property in any olher If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for wrrent year? 0 Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
201t _ 20 20 _Q� 20 �`� 20 20 20
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Signalure County Auditor Date
�� We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and lhat the applicants was / were ,
:sident of Indiana and owner of the aforemenlioned property on March 1, 20
i nature (owne/s full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
F 1 sident a ress of applican Address of authorized person
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