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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
' � FOR DEDUCTION FROM ASSESSED VALUATION
ti j State Fortn a37os (Ra / t0.01)
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PrescribeC by DepaNrent ot Local Govemment Finante
�STRUCTIONS:
To be filed in person or by mail with the County Auditor of the county whe2 the pmperty is loca�
Filing Dates: 1) Real Property: During the 12 months be%re May 11 0/ the year the deduction is
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 31 o
See �everse side (or additional instructions and qualificaGons.
Applicant ( e r contra buyer - see res clions o reverse side) ,
�
Taxing Distrid Key number / legal description Record number ��
.� n^ QI ��D� � O t�_� Page number ^� (+�
l.Q'/{� ' a O� b
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, curtent year owneR ❑ Yes ❑ No
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If no, whal is his / her exact share of interesl? I( owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicani, indicate below: Is the property in question:
❑ Real PropMy ❑ Mobile Home (IC &1.1-�
� lame of mortgagee or conirad seller
Address of moRgagee or conVacl seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sheet, city, state, ZIP code)
Dces applicant own property in any other If yes, what county? What Tazing Distrid? Has this deduction been requesled on
county in Indiana? property for current yeaR � Yes 0 No
COUNTY AUDITOR
Deduction approved in fhe amount of:
2o zo�(� zop�) zo� zo� zo�� zo 09
� �
Signature County Audilor Date
I/ We certify under the penalty of perjury lhat the above and foregoing infortnation is true and wrrect and that the applicanls was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
ignatur ners (ull name) Person authorized by duly exewted Power of Attomey
��� or by IC 6-1.1-12-.07
Full resident address f ppli ni Address of authorized person
s o
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