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, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS minty Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
Prescribed by Department of Local Government Finance FILE II
INSTRUCTIONS: File Mark
To be filed in person or by marl JUN 2 3 di+(mad with:
Filing Dales: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought.
Must be tiled or postmarked with the County Auditor or County Recorder of the county where the property is CountY Auditor
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Property.Must file with the County Auditor of the County Recorder
where the property is located during the twelve(12)months before March 31 of each year the d484€0304q fT
See reverse side for additional instructions and qualifications.
Appila owner or contact buyer-see restrictions on reverse side) -
ht Taxing District Key /legal Record �a�,
d & - f/- if - yoo- oov, .s7Y - o' t/ ln�vlml/tier of O'®
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of • Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment date.anent year assessment date,anent year date of application legal or equitable owner?
A37r000 ❑ Yes ❑ No
tf no,what is his I her exact share of interest? If owned with someone other than comma,indicate with whom
If name on road is(Diluent than that of applicant,intimate below: Is the property In question:Annually Assessed
" ❑ Real Property ❑ Annually Assessed
Mabde Home(IC 61.1-7)_
[71-(a_,Address s of mortgagee or contract seller(number and stn Co1< < n5
i��^�i///��1 h j
Name of assignee or other owner or trolls of mortgage / 1 n n 1
Address of assignee(number and street rill:state,and /n_0 :n/Fill -
Does applicant own property in any If yes,what count ` /(/(J wen requested If yes,state amount of deduction - —
other county in Indiana? ❑Yes ❑No i I anient year! LJ Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity fine of credit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR " - -
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of CounyAuctdor County Date(month,day,yew)
I/We certify under the penalty of perjury that the above and foregoing infonnafion is true and coned and that the applicant is a resident of Indiana and
owner f contract buyer of the aforementioned property on date application is filed.
)(Signature(cam name) Data(month,day,year)
Full ' ant address of applicant(number and street thy,state,and ZIP code) -
Y36Y S (coo ' wh in Y706 -S- •
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day.year)
Address of authorized person (number and street at state.and ZIPcoJe)"
The penalties for perjury can include Imprisonment up to two and a half years and a fine not to exceed S10,000.-1-1 T R g�