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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES$
= FOR DEDUCTION FROM ASSESSED VALUATION
�. � / StateForm43709(R5/a-03)
Piescribed by Depertmem of Loral Govemment Finance
�TRUCTIONS:
e filed in person or by mail with the CountyAUditor o/ the county whe2 the property is located.
Filing Dates: 1) Real PropeRy: Dunng fhe 12 months before May 11 0l the year the deductionjs,;tb Gg eff�
— 2) Mobiie Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is to be effective.
See reverse side (or additional instructions and qualificafions. � D
a — � 3 -a � - vo . g �_a�� ���o�T�;�
Applicant (gqvner or contract puy�rJ- see restnc(ions on reverse side)
Assessed value of real property as of
March 1, curtent year
It no, what is his / her exact
If name on record is
Name of mortgagee or contract seller
of mortgagee or controct seller
Name of assignee or other owner or
/ legal description
�, �..-��,�,�
Mortgage / Contract indi
March 1, current year0
S8� `�
applicant, indicate below:
Page number
- b'
iess unpaid as of Is lhe applicant the s le egal or
owner? es ❑ No
If ovmed with someone other than spouse, indicate with whom.
and street, city, state, ZIP
mortgage
• W • OJ '� Z 7J
Is lhe pioperty in question:
{,—yReal Property ❑ Mobile Home (IC E1.
Address of assignee (number and street, city, state, ZIP code �
Drawer 1\'O.a�Q.� ,�-�1........
Does applicant own property in any other If yes, what counry /� /��.�/ duction been requested on
counry in Indiana? � C8I'd NO. .. �.V. ��/, J........ ' curcent year? ❑ YesO No
� �-�� �, �U �� C
Cwn � r r�uu� i vn
approved in the amount of:
r� � —�i
20 n<: 20 oJ 20
o�
County Auditor
20 � I 20
Y
c
I
I/ We certify under the penalry of perjury that the above and foregoing information is true and correct and that the applicants was / were
a resident of Indiana and owner of the aforementioned property on March 1, 20
or by IC E1.1-12-.07
4ddress of authorized person