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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
State Form 43I09 (RS / 4-03) '
PrescriDed by DepaRment of Local Govemment Finance
INSTRUCTIONS: "� File Mark
To 6e filed in person or by mail with the County Auditor of the counry where the property is located. ��� ��--{ i �)
Filing Dates: 1J Real Property: Dunng the 12 months be%re May 11 0/ the year the deduction is to be effech�e 1/ ��
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction is to be eHective.
See reverse side /oradditional instructions and qualifications. ��N 1 1 Z���f
Applicant (owneror
see ct�o
Key
side)
/ legal description
Asses value of real properly as of MoAgage / Contrad ii
March , wrrent year March 1, current year
If no, what is his / her ezad share of interesl?
Page number
as ot I Is the applicant the sole legal or equitable
owneR ❑ Yes ❑ No
� ao6o�0I
If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate betow:
'ame of mortgagee or contracl seller ' \�
I�
Address of moRgagee or contjact seller (number�nc�,st2et„city, state, ZIP
Name of assignee
of assignee (numberand st2et,
mortgage
state, ZIP code)
♦
Does applicant own property in any other If yes, what county? What Taxing District?
county in Indiana?
Deduction approved in lhe amount of:
''�1�jI� � • - �yi
�
COUNTY AUDITOR
r � � :��
P I �
County Auddor
Is lhe property in question:
❑ Repf Pmperty ❑ Mobile Hane
.
Has this deduclion been requested on
property for curcent yeaR � Yes ❑ No
20
20
We certify under the penalty of perjury that the above and foregoing information is true and corred and thal lhe applicants was / were
resident of Indiana an� owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person