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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
S J State Fwm 43709 (RS I 4-03)
� PrescnEed by Department of Local Govemment Finance
INSTRUCTIONS:
Coun Township Year
File Mark
To be filed in person or by mail with the Counry Auditor o) the county where the property is locate
Filing Dafes: 1) Real Property: Dunng the 12 months before May 11 0/ the year the deduction is t e e�ctivg.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of th ear�e�d�ct�s f be ffective.
See reverse side for addiUonal instnrctions and qualifrcations.
OCT 2„ 2003
Applicant (owner or contrect yer - e re 'ct s on`reverse side) ( � . n�
/ �_ � ��
' !� � N
Taxin trict Key number / legal de 'ptio Record'num ' �'"" '
O
Q Q Q/� � Page number /' _
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, currenl year March 1, curcent year owner? ❑ Yes ❑ No
C� O C� C�
If no, what is his / her exact share of interest? It owned with someone other than spouse, indicate with whom.
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If name on record is diHerent than that of applicant, indicate below: Is lhe property in question:
' Real Property ❑ Mobile Home (IC 61.1-7)
te of mortgagee or conlract seller ,
Address oi mortgagee or contracl seller (number and st2et, city, state, ZI
. �.a - 3753
Name of assignee or other owner or holder of mortgage n
t a�3-�s��
Address of assignee (num6er and street, city, state, ZIP code) �_
Does applicant own property in any other If yes, what counry? What Taxing District? Has this deduction been requested on
county in Indiana? property for curtent year? ❑ Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
zo Q� zo zo zo (l� 20 � zo � zo
Q � P
Signature � County Audiror Date
1° � ��' .
-�We certify under the penalry of perjury that the above and foregoing information is true and correct and lhat the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
ignature (owners full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1•72-.07
Ful resident address of applirant Address of authorized person
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