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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS �� F' �
FOR DEDUCTION FROM ASSESSED VALUATION Crnin `1 I Township j Year
� i State Fwm 43709 (RS I 4-03) S� -4i 1-J ILJ bf
�, � P25cribeC by DepaMiant of locai Gtivemmem Finance NO 1 4�005
INSTRUCTIONS: '�a,,FilejMark
To be filed in person or by mail with the County Auditor of the county where the property is located. � �
Filing Dates: 1) Real Property: Dunng the 12 montAs before May 11 of the year the deduction is to be�e7fective OUN7Y AUDITOR
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is to be effective.
See reverse side lor additional instructions and qual�cations.
(owner or contract buyer- see 2strictions on reverse side)
Taxing Distrid
Assessed value of real property as of
March 1, wrrent year
If no, what is his / her exact share of interest?
If name on
Key number / legal desuiption Record number
01- 7U��
Page number
0o a -o�s �a - �
Mortgage / Contred indebtedness unpaid as of Is the applicant t e sole legal or equit.
March 1, current year ownef? s❑ No
lhan that of applicant, indicate below:
/Q i� .. a �JO � . �%Z - �'J�
If owned with someone other lhan spouse, indicate with whom.
O Real
moAgagee or contrad seller
Address of moRgagee or contred seller (number and street, city, state, ZIP
Name of assignee or olher owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP code)
❑ Mobile Home (IC Crt.
_ 550
Does applipnt own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been r
county in Indiana? property for current year?
7�
COUNTY AUDITOR ��-l` D� �,,
Deduction approved in the amouni of: -%� �
zo � � zo
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Signature
zo � zo�
I � �
Counry Auditor
zo �� -���`�
Date
ies�ea on
Yes❑ No
We certify under lhe penalty of perjury lhal lhe above and foregoing informalion is true and corred and that the applicants was / were
esidenl of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners full
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full �sident address of appticant Address of authorized person
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