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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�'.4 � State Fortn 43709 (RS / 4-03)
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� Presaibed by Department of Loral Govemment Finance '
INSTRUCTIONS:
To be filed in person or by mail with the Counry Auditor of the county where the property is located.
Filing Dates: 1J Real Property: Dunng the 12 montAs before May 11 01 the year the deduction is to
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0( the
See reverse side Ior additional instructions and quali�cations.
(owner or contract bpy�r - see
side},
File Mark
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yea d�du ion i�e�ve.
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OCT 14
Taxing Dislrid ` I I Key num�6er Tlegal descriptbn Record nS�rfi�ON�r„(11.�\" CI)pITOR �
����> v if�V^ ' _ � / 7 �.ii� O Page number � , -
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Assessed value of real property as of Mortgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, currenl year March 1, current year ownef? ❑ Yes ❑ No
�Q44 �
If no, what is his / her exact share of interest? If owned with someone other lhan spouse, indicate with whom.
-o1a-08-�0� 06/. 7�-00/
If name on record is diHerent than that of applicant, indicate below: Is the property in queslion:
of mortgagee or conlrad
Address oi mortgagee or contract seller (number and
Name of assignee or other owner or holder of mortgage
city, state, ZIP
Address of assignee (numberand street, city, state, ZIP code)
Does applicant own property in any other If yes, what county?
county in Indiana?
COUNTY
Deduclion approved in the amounf of:
20 �_ I 20 �_ I 20 � ' 20
Counry Auditor
/ �
3 �05'�
D
❑ Mobile Hmie QC 61.1-�
i requested on
? � Yes ❑ No
0
We certi(y under the penalty of peryury that the above and foregoing information is true and corred and lhat the applicants was�/ were
resident of Indiana and owner of the aforementioned property on March 1, 20
�na�tu/�{� (owners fu�ll/ name)/� Person auihorized by duly executed Power of Attomey
TI \n ., 11. .� 1/ �.. (� P,c or by IC 6-1.1-12-.07 .
Address of authorized person