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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
. �W� ! sute Form a37oB (RS � a-03) .
� PresaibeE Dy Departmem of Local Govemment Finance
To beRfiled�lnOperson or 6y mail with the Counry Auditor of the county where the property is loca� �`�'" 1 e�
Filing Dates: 1 J Real Property: Dunng the 12 months before May 11 of the year the deduction is to be effectivg .
2) Mobile Homes assessed under IC 6-1.1-7: 8etween January 15 and March 2 o(the ye�r7/% Jer�c��k to be etFective.
See reverse side for additional instructions and qualifcations.
Applicant
Taxing Distrid
� il,lJ
or contracf b�yer - see
�T, ',. /rl �
value of real property as of
March 1, wrrent year
no, what is his / her exact share of interesf?
If name on record is
of mortgagee or
Key
on reverse side)
description
MoRgage / Contrad indebtedness unpaid as
March 1, current year
that of applicant, indicate below:
�
of mortgagee or contrad seller (number and st�eet, city,
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sGeet, city, state, Z1P code)
Does applicant own property in any
county in indiana?
Deduction approved in the amount of:
Fz,s�7��
P I �
Signature
i � � '
/
Record number O �
Page number .� � _
Is the applicant,,, ���the''' """sole legal or equitable
owne(? �es ❑ No
9 U �
If owned with someone other lhan spouse, indicate with whom.
property
❑ Mobiie Home (IC 61.1-�
If yes, what county? What Taxing District? I Has this deduction been requested on
property for wrrenl yeaCL(_l_vo=0 No
�.0 �zS m
-��mEZ L -
COUNTYAUDITOR ��/��j�-y —
zo 0 4 zo 20
�
County Auditor
D(� -��33
We certify under the penalty of perjury that the above and foregoing information is true and corred and thal the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-t.t-12-.07
Address of authorized person