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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
� «. / State Fwm 43709 (R5/4-03) - . . . � � �
� P2scnEM by Department of Local Govemment Finance
INSTRUCTIONS: � ��;ie��,2004
To 6e filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1J Real Property: Dunng the 12 months before May 11 olthe year the deduction is to be e ectrve.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o/the y
� .0 TY AUDITOR
See reverse side for additronal instructions and quali�cations. -
Applicant (owne� or contract buyer - see
Assessed value of real property as of
March 1, current year
no, whaf is his / her exact share of interest?
on reverse
Key.number /
���.. ��
Mortgage / Contract ii
March 1, current year
If name on record is different than that of applicant, indicate below:
Record number
Page number
as of Is the applicant the sole �egal or equitable
� owner? �s ❑ No
If owned with someone other than spouse, indicate with whom.
�i�e of moAgagee or contract seller
i
s � �_��.o
Address of mortg gee or contra seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand street, city, state, ZIP code)
Does applicant ow� ����_.•.. - --__.... . _. _ - - -
What Taxing District?
county in li 9�� U_ 7b Z3
��7Sooa v�
�rn �s � � �i�,e�P,eVTYAUDiTOR
Deduction
20
Signature
20 fl�
20 � D 20 Q'L 20
P P
County Auditor
Is the propeRy in question:
❑ Mobile Home (IC 61.1
Has this dedudion been requested on
property for current year? � Yes ❑ No
20
Date
�
certiry under the penalry of peryury thal the above and foregoing infortnation is lrue and corred and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
(owners full
address �
Z S
�,
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
of authorized person