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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS county Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
�' State forth 437W(R13/10.15)
Prescribed by Department of Local Government Finance A
INSTRUCTIONS: • I e Mark
To be filed in person or by mail. ' fi:,I�e,
•
Filing Dates 1) Real Property Must be completed and dated in the calendar year for which the deduction is sought S E `
Must be filed 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 bmnediatety succeeding calendar year. •■t r; Recorder
2) Mobile/Manufactured Homes not assessed as Real Properly:Must file with the County Auditor of the county , , �.'rdlf •
where the property is located during the twelve(12)months before March 31 of each year the deduction is sow, • 1
See reverse 1. for additional instructions and qualficafons. GIBS* COUNT'
Applicant(• - contract brows reverse sidg) 1//���t Page number
Tatung DsUt 17 0 - 1,671'
V 1 - `f®_3-�� eoa Rear° ! r 4�5
Assessed value of real property as of ((�_JC�' Mortgage/Contract indebtedness unpaid as of r Mortgage/Contract'ebtedness unpaid as of Is the applicant the cis
assessment date,cement year assessment date,=rent year I date Siipicab l..�_ legal or equitable owner?
vl1r OO�IJ\ ❑ 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 record is different than that of applicant,indicate below: Is the property in question:Annually Assessed
❑ Real Property ❑ AnnuallyAssessed
Mobile Horne(IC 6-1.1-7)
Nacre of mortgagee or contact seller es J�
mortgagee Address of rtgagee or contract seller(number and steer dy,state_and ZIP redm _ _
Name of assignee or other owner or holder of mortgage
A7?
„
Address of assignee(number and steer dry,state,and ZIP code) D 1:115'C I. N O /lr,(///
Does applicant o property in any If yes,what count)? Card N O. �/ ^
wn If yes,state amount of deduction
other county
in Indiana? ❑Yes ❑No
A person is not entitled to this deduction unless the person ha __Jess that is recorded in the county
recorder's office(including any home equity line 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 County Auditor County - Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner!contract b r of the afore ntioned property on date -••' ;•n is fried.
- re(owners name) Date(month,day,year)
14 address Fent' umber- city,ate.and ZIP code)
Person authorized by duly -r r ed Power of Attorney or by IC 6-1.1-12-0.7 - Date(month,day,year)
Address of authorized person (number and street city,state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.