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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S�M� ! State Fwm 43709 (R5 / 4-03)
� Presaibed by Department ol Laal Govemment Finance
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INSTRUCTIONS: !. • . � -File Mark
To 6e Cled in person or by mail with the County Auditor of the county where the propeRy is located.�– -�–�— �...... ., �.._.�
Filing Dates: 1J Real Property: During the 12 months before May 11 of the year the deduction is to be e/fective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the�lyea� f�e�l�Cpn is to 6e efrective.
See reverse side lor additional instructions and qual�cations. / /�
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Applicant(ownerorcontraclb er- e2sMct' nson erse i e) -" �" "'" ` •
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Taxing Distrid Ke ber / legal desuip on Record number 0"�
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/ /���� /� /� _ ��Q% Page number � �
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Assessed value of real property as o Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, currenl year March 1, currenl year owner? ❑ Yes ❑ No
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If no, what is his / her exacl share of interest? Ii owned with someone other than spouse, indicate with whom.
If name on record is different ihan that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-�
�me of moAgagee or contrad seller
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Address of mortgagee or conVad seller (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP code)
Does applicant own property in any other If yes, what counry? What Taxing District? Has this dedudion been requested on
counfy in Indiana? property for curtent year? � Yes � No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �� 20 � i 20 ,� � 20 �_ 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 lhe oremenlioned property on March 1, 20
gnat (ow s!ul am@),.� Person authorized by duly executed Power of Attomey
��; or by IC 6-1.1-12-.07
F II resident a dress of applipnt Address of authorized person
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