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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION -fC�ou�n `__{ Township Year
1�/ State Fortn 43709 (RS I 4-03) Lt� F� i� �+.� �
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� PresaiEetl by Department o( Local Govemment Finance �l Ji 1 1LJ
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INSTRUCTIONS: /� File Maric
To be filed in person or by mail with the County Auditor of the counry where the propeKy is located.� /J
Filing Dates: f) Real Property: Dunng the 12 months be/ore May 11 0l the year the deduction is to�'be eflective_ -�-�-�{�,,
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2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of (Fie year 11ie �deduction�is�tqbe,�ctive.
See reverse side for additional instructions and qualifications.
Applicant (own r r contract 6uyer - see restrictions on iev e side) ,
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Taxing Dislrid Key number / legal descriptio Rewrd numbe
�i w`-�' ` � J-�014 9-oo Page number ���
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Assessed value of real properiy as of Mortgage / ContraIX indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1 current year owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
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If name on record is different than ihat of applicant, indicate belo � Is the property in queslion:
p❑ Real Property ❑ Mobile Home QC 61.1-�
�me of moRgagee or conlrad seller
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Address of mortgagee or contraIX seller (number and st�eet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for current year? � Yes � No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 0 20 �� 20 � 20
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Signature � County Auditor Date
�! We certify under the penalty of perjury that the above and foregoing information is true and correct and lhat the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
i a e(owners full nam ) Person authorized by duty executed Power of Attomey
O � or by IC 6-1.1-12-.07
Fu resident address of app nt Address of authorized person
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