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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDN
' FOR DEDUCTION FROM ASSESSED VALUATION � oun nship Year
� «. J State Fom:437091R5 / ap3) - � . � : � �
Prescnbetl by Departrtrem of Lotal Gdvemment�Finance
INSTRUCTIONS � `� � Fi�e Mark
To 6e filed in person or by mail wiih the CountyAuditor of the county where the propeRy is IocaYeA.a
Filing Dates: 1) Real Property: During the 12 months before May 11 0l the year the dedu�(gS�,f�ti �p�TOR '
2) Mobile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 0/ the year the deduction is to be effective.
See reverse side (or additional instructions and qualifications. ,
Applicant (ownerorcontracf 6u er- see restrictions on v e side)
� �
Taxing trid Key number / legal description
�/ :.
� l 9 -c��ao - �.
Assessed value of real property as of Mortgage / ContraG indebtedness
March 1, current year March 1, current year .
no, what is his / her exact share of interest?
Ii name on record is different lhan that of applicant,
moRgagee or conlrad sellel
/
' I If owned
below:
Address of mortgagee or conlrad seller (number and street, city, state, ZIP
�
Name of assignee or other owner or holder of mortgage
of assignee (numberand street city, state, ZIP
Record number
unpaid as of Is lhe applica the sole legat or equitable
� owner? es ❑ No
Does applicant own property in any other I If yes, what county? What Taxing Distrid?
counry in Indiana?
COUNTY AUDITOR
Deduction approved in the amounl of:
20 0� 20 _{�_ 20 �� 20 20
V � �
Signature County Auditor
than spouse, indicate with whom.
❑ Mobile H«ne pC 61.
Has this deduclion been requested on
property for current year? � Yes ❑ No
20
Date
20
certify under the penalty of perjury that the above and foregoing information is true and corred and that lhe applicants was / were
lent of Indiana and owner of the atorementioned propeAy on March 1, 20
Person authorized by duly executed Power o( Atlorney
or by IC 6-1.1-12-.07
�ess or appucam ' IAddress of authorized person
� ,-� �4 v�9 � S