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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
++ �� J State Fwm 43709 (R5 / 4-03)
Presaibed by Depariment of Loral Govemment Finance
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INSTRUCTIONS: File Mark
To be filed in person or by mail with the Counry Auditor ol the county where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 months belore May 11 0/ the year the deduction is to be e/fective.
2) Mo6ile 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 for additional instructions and qual�cations. [�' �'�"
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or confiact bu��- se� resfrictions
Key number / legal
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Assessed value of real property as of Mortgage / Contred u
March 1, curtent year March 1, current year
g,
If no, what is his / her exact share of interesl?
If name on record is different than that of applicanl, indicate below:
of mortgagee or contract 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 stieet, city, sfate, ZIP code)
Does appliwnt own property in any other I If yes, what county?
county in Indiana?
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Signature
approved in ihe amounl
20 _�7(� � 20
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�ss unpaid as of
, �.,
Page number
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r��� U 2 2004
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Is the applicant the sole legal or equitable
owne(? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
s the property in queslion:
❑ Real Properiy ❑ Mobile Hane QC Cr1.1-�
ZIP
What Taxing District? Has this dedudion been requested on
property for current year? � Yes 0 No
COUNTY AUDITOR
20 _Q�
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County Auditor
20 Q� 20
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Date
20
I/ We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that ihe applicants was / were
1resident of Indiana and owner of the aforementioned property on March 1, 20
/ull name)
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
of authorized person