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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNES�
FrJR DEDUCTION FROM ASSESSED VALUATION
sute Fw�, a37os (rts i a-03� ,
Prescribetl by DepaRment of Lacal Govemment Financa
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of fhe counry where the property is ,
Filing Dates: 1) Real Property: During the 12 months before May 11 o/the year the deduciion is to be q�ti�(p.s Z��6
2) Mo6ile Homes assessed under IC 6-1.1-7: oetween January 15 and March 2 of the y�h�e deduction is to 6e eNective.
See reverse side for additional instructions and qualifications.
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uN7Y AUDITOR
Applicant (owner or cont t uyer see restrictions on rever e ide)
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T �ng nd Key numbe / egal description Record number �
a� � O —O �/ Page number � �-j
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Assessed vatue of real property as of MoRgage / Contrad indebtedness unpaid as ot Is the applicant t e le legal or equitable
March 1, curcent year March 1, curtent year owne(� ❑ No
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If no, what is his / her exad share of interesl? If owned with someone olher lhan spouse, indicate with whom.
If name on recard is different ihan that of applicant, indicate below: Is the property in question:
- ❑ Real Property ❑ Mobile Hane QC Cr1.1-�
�me of mortgagee or conVad selier
Address of mortgagee or contrad selier (numb and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (nurnber and sheet, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has lhis deduction been requested on
county in Indiana? property for current yeaR� Yes❑ No
COUNTY AUDITOR
Deducfion approved in the amount of:
20 �_ 20 ��_ 20 �0 `% 20 20 20 20
1 �
Signature County Auditor Date
�We certify under the penalty of perjury that the above and foregoing information is irue and corred and that ihe applicants was / were
re ' ent of Indiana and owner of the aforementioned property on March 1, 20
S' a r owners (ull name Person authorized by duly exewted Power of Attomey
� or by IC 6-1.1-12-.07
F I esident address of applicant Address of authorized person
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