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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Townshi Year
�� w� / Sfate Form 43709 (RS / 4-03) � �. i
� Piesaibe0 by Depanment of Local Govemment Finance ��_� j: .��
SEP 2 0 2C05
INSTRUCTIONS: File Mark
To be filed in person or 6y mail with the CountyAUditor of the county whe�e the property is located. �-y,,
Filing Dates: 1) Real Property: Dunng the 12 months before May 11 of the year the deduction is ro be eflective. 0'� %� ���
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year th��otfeduction����o be�e%ch�uhe.
See reverse side for additional instructions and qualifications.
Applicant (owneror
Distrid
Assessed value of real property as
March 1, current year
ffon�n v r e side) �
/
Key number / leg�a}' description
�G /3-/3—i'oa-0oi a�s-a�� � �
� b/�-plo�soa P�
MoAgage / Contract indebtedness unpaid as of
March 1, current year
��� (,I.�uo
If no, what is his / her exaa share of inleresl?
If name on record is diHerent than that of appticant,
of mortgagee or contrad seller
Address ot mortgagee or conlrad seller (number and st2et,
of assignee or other owner or holder of mortgage
of assignee (numberand street, city, state, ZIP
Does applicanl own property in any olher I If yes, what county?
county in Indiana?
Deduction approved in lhe amount of:
20 Q� 20 �_ 20 Q
Q � P
Signature
xd number
: number
Is the appli
owner?
l fhe sole legal or equitable
❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
ZIP
s the property
❑ Real Property ❑ Mobile Hane pC 61.
�OoG-�3�
-�o�!-c � :. `�� /, 7c�. ee
4�'� � n requested on
I �la�p 3(�� Yes❑ No
—� ca„�w�dG Ncma�o _
COUNTY.. _
20 20 20 20
County Auditor
We certify under the penalty of perjury thal the above and foregoing information is true and corred and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
name)
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07 �
oenc anaress ot appucaJr i IAddress of authorized person
i� n. �,�0 � -C. �s�.� _ �/7�� 1�