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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FQR DEDUCTION FROM ASSESSED VALUATION � Year
�• �«� �/ StatB Fwm 437p9 (RS / 4-03)
. PrescnDed by Depanment of Local Govemment Finance
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INSTRUCTfONS: _ File Mark
To be fifed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real P�operty During the 12 months be%re May 11 of the year the deduction is fo be eH�v ���
2) Mobile Homes assessed underlC 6-7.1-7: Between January 15 and March 2 of th�aF-tH�H"�cTt�r��s����eHective.
See reverse side for additional instructions and qualifrcations.
tippucam �owne� or conrract nuyer- see restncbons on reverse side)
Taxing Distrid Key numb / leg description Record number
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' J� Page number %
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applipnt�sole legal or
March 1, current year March 1, wrrent year owne(? es ❑ No
If nq v�hat is his / her exact share of interest? �(
If name on record is different than that of applicant, indicate below:
ci mortgagee or contract selier
Address o�norigagee or contract selier (number and st�eet, city, state, ZIP
tJame of assignee or other owner or holder of mortgage
r:ddress oi assignee (number and streef, city, state, ZIP code)
with someone other than spouse, indicate with whom.
Does applicant own property in any other I( yes, what county? I What Taxing Distrid?
county in lndiana?
COUNTY AUDITOR
)eductibn approved in the amount of:
20 20 _� 20 � 20 20
� I
iignature County Auditor
the property in questian:
❑ MoGle Hane (IC frt_
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Dra���er NO�: ..
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Card NO _ ,�`• • • \..
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20
Date
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We certify under the penalty of perjury that lhe above and foregoing information is true and correct and thal the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
(ull name) %}_-�-�'
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Person authorized by duty executed Power oi Attomey
o� by ic s-i.i-iz-.o�
run resioent aaaress oyjappucant Address of authorized person
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