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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FFOOF DorrnE�DUCTION FROM ASSESSED VALUATION
(q�( 71Prescribed by Department of Local Government Finance JI �..1/� � - _`o \1
INSTRUCTIONS: • File Mark
To be filed in person or by mail. Form filed with:
Filing Dates 1) Real Properly Must be completed and dated in the calendar year for which the deduction is sought
Must be filed or posbnarked 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 County Recorder
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications. Ro...,.. ....y.Th ,„
Appfiratt(��rer`roo,boa dvye�-(ree�rc reverse side) ,\" ""\1,1 _ CVT l!./I` r 1 Record number Page n tier
I Ket , - = 303-0003L1-Uvc' , 20 c 2
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortga /Contract indebted unpaid as of Is the ap ' nt the sole
,xea<-nrem date,current year assessment date,current year date legal [table owner?
OOylifif JJl11�O— • Yes 0 No
If no,what is his/her exact share of interest? Darned with other than spouse,indicate with whom
If name on record is different than that of applicant,indicate belw - .I'n a property in question:Annually Assessed
40 / p _ y 5 Real Property ❑ Annually Assessed
/ or Mobile Home(IC 6-1.1-7)
Name of mortgagee or contact seller rT fc
G 1 T l u . Drawer NO J1��I I,} .
Address of mortgagee or contract seller(number and street col: T
Name of assignee or other owner or holder of mortgage Card NO.
JUL 1 2 2019
Address of assignee(number and street,city,state,and ZIP code) li
DDoes oer n1Y applicant own property in any If yes,what county? What Taxing District? - onHas this deduction taliarENIM4tglt� i K deduction
in Indiana? ❑Yes ❑No currentptyyeary?for ❑Yes 0 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 line of credit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction ap in u of ////
2 20 • 20 ' 20' 20
1
Sig tore Auditor County �� Date(`m• �ofmM pip ni
I We ce ' r the penalty of perjury that e above and foregoing information is 1 and correct and that the applicant is A111 idof Indiana and
own ct buyer of the aforementioned property on date application is filed.
`( Signature(owner's name) Date(coo Zday a>y ,
x\ `r06 �s�aJ�/est S k fiac�.t - Jul r�
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,yeah)
Address of authorized person (number and street dty,state,and LP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.