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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDt1CTION FROM ASSESSED VALUATION
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Rpaibed by DapaNnerit af Local Govemmant Finance
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INSTRUCTIONS: File Mark
To be filed in person or by mail wilh the CountyAudito� of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months before June Il o( the yea� the deduction is fo be eftective.
2) Mobile Hoines assessed under IC 6-1.1-7: Between January 15 and March 2 0( the yea� the deduction is to be elfective.
See reverse side for additional instructions and qualifrcations.
lippli owneror conhact buyer- see �estn ns reverse side)
T�ng Distrid Key number / legal description Record number
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Assessed value of roaf property as of Morigage / Contrad indebtedness unpaid as of Is the applicant,,,��1tkk,h,,e���sole legal or equitabte
March 1, curtent year March 1, curtent year owneR �es ❑ No
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If no, what is his / her exad share of interest? If owned wilh someone other than spouse, indicate with whom.
If name on record is dABrent than that of applicant, indicate below: Is the property in question:
eai PropeAy ❑ Mobile Home QC 61.1-�
�me of mortgagae a conVact seller �
Address of mortgagee or contrad seller (number and street, city, state, ZIP
Name of asefgnee m other owner or holder of mortgage
Address of asaipnee (rtumber and sheet, city, state, ZIP code)
Dces appHcard own property in arry other If yes, what counry? What Taxing Distrid7 Has this dedudion been requesled on
county in Indiana9 property for current yea(t � Yes� No
COUNTY AUDITOR
Dedudion approved in the amount of: ,
20 A4� 20 � 20 20 20 20 20
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Signature County Auditor Date
� We certify under �fre penalty of perjury that Ihe above and toregoing infortnation is true and correct and thal ihe appliwnts was / were
:sident of Indiana and owner of the aforementioned property on March 1, 20
S�ture (owners /uU name) � Person authorized by duly executed Power of Attomey
. r�y . or by IC 6-1.1-12-.07
Full res�denf dress of applipnt • Address of authorized person
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