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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�• ! State Fwm e37W (R5/4-03) . � .
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PrescnEeO Cy Department ol Local Govemment Finance
INSTRUCTIONS:
Coun Township Year
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FEB 0 6 2006
File Mark
To be �led in person or by mail with the County Auditor ol the county where the propeRy is located. �-y,,
Filing Dates: 1) Real Property: During the 12 monfhs before May 11 of the year the deducfion is to be elfecGNE! ��
2) Mobile Homes assessed under IC 6-1.1 J: Between January 15 and March 2 0/ the ye������e�l�q,(s��ctive.
See reverse side 1or additional instructions and quali�calions.
Applicanl (owner or tract buyer- see restnr,tiqns o�e e side)
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Tacing District Key number / legal description Rewrd number /-�
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Assessed value of real property as bf Mortgage / Contract indebtedness unpaid as of Is the appliqnt the sole legal or equitable
March 1, current year March 1, wrrent year ownef? ❑ Yes ❑ No
If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on rewrd is different lhan that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Horne QC 6-1.1-�
�me of mortgagee or conlrect seller ' `
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Address of morigagee or contrad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this dedudion been requested on
county in Indiana? propeAy for currenl year? � Yes� No
COUNTY AUDITOR
Deduction approved in ihe amount of:
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Signature County Auditor Date
/ We certify under the penalty of perjury thal the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
ture (owner� Person authorized by duly executed Power of Aftomey
^ or by IC 6-1.1-12-.07
Full resident address of applicant Address of authorized person
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