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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
� FQR'DEDUCTION FROM ASSESSED VALUATION
w� �! State Fortn 43709 (RS / 4-03)
� ' , PrescnDed Oy Departmem of Local Govemmem Finance
Coun Township Year
INSTRUCTIONS: File Mark
To be. /iled in person or by mail with the Counry Auditor of [be county where the property is located.
Filing Dafes: 1) Real Property: During the 12 months belore May 11 0/ the year the deduction is to be eHective.
• 2) Mobile Homes�assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the dedu ion is to be elfective.
See reveise side for additional instructions and qualiFications. l���
-_'-" . ., '
Applicant (avne� or ci
Taxing Distrid
� ��
Assessed value of re:
March T, �wrrent year
GTiI
Key number / legal
6/6 -�o� �
as of Mortgage / Contract ii
March 1, current year
If no, what-is his ! her exacl share of interest?
If name�on record is different than that ot applicant,
of moRgagee or contract selfer
u� � � 4 2005
Record number r,.•
C� � � "3 ,a'
J/ Q � Page number �/'� �'JUN I Y AUUI
1( ��
iebtedness unpaid as of Is the applicant the sole legal or equitable
owneR ❑ Yes ❑ No
O�p�� �
If owned with someone other than spouse, indicate with whom.
Address of mortgagee or contrad sellei number �d street,
Name of assignee or other owner or holder of mortgage
below:
assignee (number and st2et, city, state, ZIP code)
Does appiicant own property in any other I If yes, what county? What Taxing District?
county in Indiana?
approved in ihe amount of:
20 Q �/
Signature
20 �
�
COUNTY AUDITOR
20 �_ 20 20
P
County Auditor
❑ Real Property ❑ Mobile Home (IC 61.1-�
Has this dedudion been requested on
property for current year?0 Yes� No
20
�
We�certify under the penalty of perjury that the above and foregoing information is true and correct and thal the applicants was / were
resident of indiana and owner of the aforementioned propeRy on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
authorized person
l