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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION -Coun --t Townshi�pI -- Year
S,�w� J StaleFwm63709(R514-03) �� t:,� j.'�l (J �
� Prescribed by Department of Local Govemmeni Finance �� �l—y
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INSTRUCTIONS: � File Mark
7o be filed in person or 6y mail with the County Auditor of the county where the property is located.�
Filin Dates: 1 Real Pro e Durin the 12 months belore Ma 11 of the '"" �
9 ) p rtY: g y year the deduction is to be eflective. � �
2 Mobile Homes assessed under IC 6-1.1-7: Between Janua 15 and March 2 of the �QC�'` `
1 ry year4fie deduction is to be eNective.
See reverse side (or additional instructions and qualifications.
Appticant (owner or contract buyer - see restrictions on reverse side)
Taxing Dislrid Key number / legal descriptio Record number O�
� O Q ^�a Page number � �
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Assessed value of real properry as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March t, curtent year March 1, current year owne(? �es ❑ No
�.Q
If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different lhan lhat of appticant, indicate below: Is the property in question:
Real Property ❑ Modle Home (IC 61.1-�
' ' 3me of mortgagee or conlrad seller
Address of moRgagee or contrad selier (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sfreet, city, sfate, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for current yea(? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amounl of:
20 fL� 20 �,� 20 20 �1 20 �_ 20 � 20
V � /I
Signalure County Auditor Date
�/ We certify under the penalty of perjury lhat the above and foregoing information is true and corred and that lhe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
I Signatur wners full nam ) � Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
u resident address of plicant Address of authorized person
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