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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
♦ _- , State Portn 43709 (R5/ d-03) �
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P2sai�ed q� Departmem of Local Gtivamment Finarxe
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INSTRUCTIONS: � Fqe Ma� �
To be fifed in person or by mail with the CountyAUditor o/ fhe counry where the property is located. ��•J
Filing Dates: 1) Real Property: During fhe 12 months before May 11 0/ the year the deduction is to 6e eflecfivQ.��
2) Mobile Homes assessed under IC 6-1.1-7: Beiween January 15 and March 2 0/ fhe year the d�6`dcti�n,`� ��Rective.
See reverse side for additional instructions and qualifications. � , �
(owner or
ItlAlll IJlll 1// `/-
I
Assessed value ofrealproperty as af
March 1, curtent year
If no, what is his / her exact share of interest?
Key
�
er/legal
9-c
number
/ � /�/ � Page number
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rtedness unpaid as of Is the api
1 the sole legal ar equitable
March 1, current year owneft ❑ Yes ❑ No
,�5�0 � d
If owned with someone other than spouse, indicate with whom.
I( name on record is different than that of applicant, indicate below:
of mortgagee or conlrad seiler
Address of mortgagee or contred seller (number and streef, 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 propeRy in any other If yes, what counry? What Taxing Distrid?
county in Indiana?
Deduction approved in the amounl of:
20 f�� I 20
COUNTY AUDITOR
20 20 � 20
County Audilor
s the property in questfon:
❑ Real Prope�ty ❑ Modle Home pC 67.1
Has this dedudion been requested on
property for currenf yeaf?Q Yes� No
20 � 20
P
Date
/ We certify under the penalty of perjury that 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
ignature (owners lull name) Person authorized by duly exewted Power of Attomey
_ /.' �i` ) / � )� � or by IC 6-1.1-12-.07 —
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resident address of appliqnt � �Address of authorizetl person