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rt"' STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' ' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S � / Slate FOm143709 (R4 / 10.01)
�u.
� PreSCribeA by Departmenl o/ Local Govemment Finance
� RUCTIONS: � LI — 1�� �� Fife Mark
To be filed in person or by mail with �County Auditor ol the county whe2 the property is locafed.
Filing Dates: 1J Real Prope�ty: During the 12 months be%2 May 11 0/ the year the deduction is to be effecti
2) Mobife Homes assessed under IC 6-1.1-7: Befween January 15 and March 31 0/ the r h�e ctio 's t ective.
See reverse sid� lqr�itional�t�� � nd pudlifications. � �PR 2QD,L n
� � �� 3� 11
see restriction on reverse side)
�- ��r � �/
Key numb / legal description
� ��`�/ d � � — O S�o SS<-oa `
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of
March i, current year March 1, current year
_ �
If no, what is his / her exact share of
number
Is the applicant the sole legal or equitable
ownef? ❑ Yes ❑ No
If owned with someone other lhan spouse, indicate with whom.
If name on record is different than lhat of applicant, indicate below:
� e of mortgagee or contr ler
��x
Address of mortgagee or contrad seller f mber and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand street, city, state, ZIP code)
Does applicant own property in any other If yes, what county?
county in Indiana?
Deduction approved in the amount of:
zo� � � 20
S
What Taxing Dislrict?
COUNTY AUDITOR
20 � 20 � 20
County Auditor
Is
O Real PropeAy ❑ Mobile Home (IC &1.
Has this dedudion been requested on
property for wrrent yea(? � Yes � No
2�
Date
P I 20�
P �
I/ We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
�sident of Indiana ayt�pwner of the aforemenlioned property on March 1, 20
Person authorized by duty executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person