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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwrt: a37W (RS / a-03)
PresaiDeE by Departmeni of laal Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the Counry Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 montAs belore May 11 of the year the deduction is to be effecti� R 4 2005
2J Mobile Homes assessed under IC 6-1.1-7: Belween January 15 and March 2 of the year the deduction is to be eRective.
See reverse side for additional instructions and qualifications.
r_�acn�.n��NTY AUDITOR
Applicant (owne� or c tract buyer - see restncC on reverse sid4�
I
Taxing Distrid K y umber / legal description Record nu
� �' ��. � `7 ( /f(_/yS Page number
OC 7 �) ��t�J
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, current year � ownef? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? Ii owned with someone other than spouse, indicate with whom.
If name on record is diHerent than that of applicant, indicate below: Is the property in question:
❑ Real Pmperiy ❑ Mobile Home QC S1_1-�
��ne of mortgagee or contracl seller
Address o( mortgagee or contracl seller (number and street, �ity, state, ZIP
(].JC�.
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sUeet, city, state, ZIP code)
Does appliwnt own property in any other If yes, what wunty? What Taxing Dislrict? Has this deduclion been requested on
county in Indiana? property for current year?Q Yes� No
COUNTY AUDITOR
Dedudion approved in the amount of:
20 20 � 20 �� 20 O�_ 20 20 20
� $� P
Signature County Auditor Date
� We certify under the penalty of perjury that the above and foregoing information is true and correct and that lhe applicants was / were
sident of Indiana and owner of the aforementioned property on March 1, 20
S nature ne s fu me) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
I resident address of applicant Address of authorized person
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