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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
L �� ! Siate Fwm a370y (RS / 4-03) ' � �
Township I Year
� PresrnEed Dy Department of Loral Govemmeni Finarxe �
INSTRUCTIONS: ' Y ` �`. ; � �M
To be filed in person or 6y mail with the County Auditor o) the county where the property is located. ��� �
Filing Dates: 1J Real Property: Dunng the 12 months be%re May 11 0l the year the deduction is to be ive.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Marcb 2 0/ the yea� ��cjion.ls to be eHective.
See reverse side /or additional instructions and qualifications. �'�
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Taxing
buyer- see re�t �tions on re�rse side) �
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Key number / legal
Record number
�j ,_� �/� O� n n n_�a Page number �� �
✓LUt" ///
Assessed value of real property as of Mortgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, wrrent year owner? ❑ Yes �❑ No
L� �
If no, what is his / her exacl share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicanl, indicate below:
�e of moAgagee or contreq seller . �
�
Address of mortgagee or contracl seller Spyrn er and street, city, state,
Name of assignee or other owner or holder of
Address of assignee (num6er and sVeet, city, state, ZIP code)
Doe ���,/�' � �} E l�Z I' Y d county? What Taxing Distrid?
coui � p
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20
Signature
05- 4ao
COUNTY AUDITOR
2� � I z� � 2� � 4 2�
P
County Auditor
s the property in question:
❑ Real Property ❑ Mobi�e Home QC 61.1-�
Has this deduction been requested on
property for current year?Q Yes� No
20
Date
�
We certity under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
�sident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by
or by IC 6-1.1-12-.07
Full resident address of applicant IAddress of authorized person
of Attomey