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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS �� �' T '��
FOR DEDUCTION FROM ASSESSED�VALIUATION �'Coun f� Tov
StateFOrm43709�R5/4-03) I'�--{ �� 4i� I� �' __ —�
Prescnbed by Depanmeni of Local Govemment Finan�_ i 1i_.m' Sk r 3 t 2004
0 C I t; � 2004
INSTRUCTIONS: � � ��.�-�i�,JJ�F le _�a,�"r c f/
To be filed in person o� by mail with the County Auditor of the county whe2 the prope�ty is locate�d SOt� COU� Y q�ip, i OR �
Filing Dates: 1) Rea/ Property: Dunng the 12 months 6etore.May 14�ol.fiie year the deduciion is to be eBective.
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2) Mobile Homes assessed under IC 6=l 1-Z:;`Between�January�l5;and March 2 0/ the year the deduction is ro be effective.
See reverse side for additional instructions and qualifications.
Applicant owner or contracf buyer- e rictions on reve � e)
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Tazing Dis 'd Key nuryber egal descriptio90 ecord number
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Page number � �s
As sed value of real property as of MoAgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, curr� year owneR ❑ Yes ❑ No
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I( no, whal is his / her exact share of interest? ' If owned with someone other lhan spouse, indicate with whom.
If name on record is different lhan that of applicanl, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home QC E1.1-�
�me of moRgagee or contrad seller •
Address of morigagee or contrad seller (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand st2et, city, sfate.11v.Mde)
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Does �M ty? What Taxing Distrid? Has this dedudion been requested on
count. ��L �. O� �� properly for wrrent year?�] Yes❑ No
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bl�i ��"� `.OUNTYAUDITOR
Deduct
20 �/ (.� 20 �� 20 �� 20 Q� 20 20 20
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Signature County Auditor Date
�/ We certi(y under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
Si nature (owners (ull name) � Person authorized by duiy executed Power of Attomey
����_ or by IC 6-1.1-12-.07
F I resident address of applicant Address of authorized person
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