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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION C n p Tow s i Year
y. M� / State Fwm 43709 (RS / 4-03) ����
� P25pip¢d by DepartmaM ol Loral Gcvemment Finance
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INSTRUCTIONS: �-y,, File Maric
To be filed in person or 6y mail with the CountyAuditor of the county where the property is located. O'/a°y. ��
Filing Dates: i) Real Property: During the 1? months before May 11 01 the year the deduction is to beB(�t�vg� NUTY AU iT
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Marzh 2 of the year the deduct�on �s to Be �ctive.
See reverse side (or additional instructions and qualifications.
(owne� or contract buyer- see restrictions on reverse side)
n n n .�,-- . ,. • ..
Taxing
Assessed value of real property as of
March 1, curtent year
no, what is his / her exact share of interest?
if name on record is different than that
of mortgagee or contract selier
Key numbe�legal description Record number
�,�,_ l3 -ao-a oo - oo/, i7o-oo � Ca
QQ � _ Q Page number �q ��
Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year ownef? �Yes ❑ No
45 a
If owned with someone other than spouse, indicate with whom.
indicate below:
Address of mortgagee or contraG seller (number and st2et, city, state, ZIP
Name of assignee or
of
owner or holder of mortgage
(numberand sfreet, city, state, ZlPcode)
Does applicant own property in any olher I If yes, what county? What Taxing Distric
county in Indiana?
Deduction approved in the amounl of:
20�Z
Signature
20 �g_
1
20
COUNTY AUDITOR
� I f�
_ County Auditor
20
Is
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❑ Mobile Home pC 61.
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Date
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20
certify under the penalty oi perjury that lhe above and foregoing information is true and corred and thal lhe applicants was / were
lent of Indiana and owner o( the aforementioned property on March 1, 20
ire (owners full name) Person authorized by duly executed Power of Attorney
. 1i, .r.... _ _ � (.. � . .. , . , or by IC 6-1.1-12-.07
of applicant Address of authorized person