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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (R5 / 4-03)
Pmscnbetl Dy Department of Laal Govemment Finance
Coun Township Year
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To beRfiled�'n�person or by mail with the County Auditor ol the county wheie the property is located. � � �e � ��2��3
Filing Dates: 1) Real Property: Dunng the 12 months befo2 May 11 0/ the year the deduction is to 6e eBecfive. �,
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the yearlhe deduyction'is to,6e effective.
See reverse side for additional instructions and qualifications. �'-�-�"'�,/�"J ��`"`'��"�
' Gi3°ON CO�J�TV AUDI70R
orcontract 6uyer- see restrictions on reverse side)
• _ n n . . n n -
Taxing Dislrid
Assessed value of real property as of
March 1, cunent year
no, what is his / her exact share of interest?
Key number / legal description Record number
03
p Page number +�q
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MoAgage / Contrad indebtedness unpaid as of Is lhe applicant,,,(((t---h���e...'''sole lega or equitable
Marchl,currentyear owne(? �res ❑N
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If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
moAgagee or contraci seller
Is the property
Address of mortgagee or contracl seller (number and street, city, state, ZIP `�
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and st�eet, ciry, state, ZIP code)
Does applicant own property in any other If yes, what counfy?
county in Indiana?
Deducfion approved in the amount of:
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❑ Mobile Home pC 61.1
Drawer NO, Q,1-„ 2 9 c�ly
Card NO. .........
COUNTY AUDITOR
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County Auditor
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Iww��y�,.,..,...-' � -r?�YesONo
zo �'� 20�
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We certify under the penalty of perjury ihat the above and foregoing information is lrue and corred and lhat the applicants was / were
resident of Indiana and owner of lhe aforementioned property yn March 1, 20
full
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Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of applicant � � �Address of authorized person