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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (R5/ 4-03) �
P2scribetl �y Department of Loral Govemmeni Finarice
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INSTRUCTIONS: � � S� �� ,a,File Marlc:i ��/
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months be%re May 11 of the year the deduction is to be effecUve. � k 2004
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0! fhe /ye�ar the deducti/on/ is to be eftective.
See reverse side for additional instnictions and qualifications. (/ _ / �,/, n n
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Distrid
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act 6uyer - see restrictions on
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Assessed vatue of real property as of
March 1, current year
Key number / legal description
C)03-o�y55-4
Mortgage / Contrad indebtedness
March 1, current year
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Record number��l
OC CiC.J C
Page number � � �
as of Is lhe applicant the sote legal or-equitable
owner? � Y�� No
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If no, what is his / her exad share of interest? If owned wilh someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is lhe property in question:
___ lQR€al Property O Mobile Horrie pC 61.
of mortgagee or contrad seller �}
Address of mortgagee or contract seller (number and street, city,
Name of assignee or other owner or holder of mortgage
Address of assignee (num6erand st2ef, city, state, ZIP code)
Does applicant own property in any other I If yes, what county?
county in Indiana?
Dedudion approved in the amount of:
20
Signature
20 ��
ZIP
wha� Taxina.Distrid? � Has this dedudion been requested on
yeaf? � Yes ❑ No
Drawer NO:...��,,,;,
couNr Card \O � �� a
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`�'war na�.�n� b�l�
20�� 20 b� 20
P P
County Auditor
20
Date
20
certify under the penalty of perjury that the above and foregoing information is true and correcl and thal ihe applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duty executed Power of Attomey
or by IC 6-1.1-12-.07 �
of authorized person