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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
b � State Form 43709 (R5/4-03)
�«•
� PrescriOed by Departn:em of Lopl Givemment Finance
INSTRUCTIONS: � � r i}�—File��
To be filed in person or by mail with the CountyAUditor of the county whe�e the property is located. ��•� 11J
Filing Dates: 1 J Real PropeRy: Dunng the 12 months be%re May 11 01 the year fhe deduction is to be effective.
2) Mobile Homes assessed �mder IC 6-1.1-7: Between January 15 and March 2 0( the �'sar the �e�pn is to be elfective.
See reverse side for additional instruct s � qual�cations.
(owner or contracf buyer
Taxing Distrid
on
Key number / legal
Q�(Gw. ,Q
number � C
J
1/ i� ti\ I Page number �/ �v
`'i C-LJ
Assessed value of real property as of MoRgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or e
March 1, curtent year March 1, current year owneR ❑ Yes ❑ No
� Oba /3-�0- _ �•Oi�a��
If no, what is his / her exact share of interest? Ii owned with someone other than spouse, indicate with whom.
If name on record is differeni than that of applicant, indicate below:
'me of mortgagee or contrad seller , ` � � � �
"l/
Address of mortgagee or contract seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
of assignee (number and street, city, state, ZIP code)
Does applipnt own property in any other I If yes, what county? What Taxing Distrid?
county in Indiana?
Deduction approved
20
Signature
COUNTY AUDITOR
in the amounf of:
20 � 20 �� i� 20
P �° 3
County Auditor
❑ Real Property ❑ Mobile Home (IC 61.
nas inis aeaucuon oeen requescea on
property for wRenl year7 �] Yes � No
20
Date
20
We certi nder the penalty of perjury that the above and foregoing infortnation is true and correct and that the applicanls was / were
�esid of Indiana and owner of the aforemenlioned property on March 1, 20
of
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person