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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Stete Forrt: 43709 (RS / a-03)
�. PrescriDed by Department ot Local Govemment Finance
1� UCTIONS: ��' �� �i 1 11File M� dc�'
To be filed in person o� by mail with the County Auditor of the county where the property is located.
Filirig Dates: 1J Real Property: Dunng the 12 months be(ore May 11 o/the yearthe deduction is to be•"eRectiie!) 2003
2) Mobile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 of fhe year the deduction is to 6e /e�Hective.
See reverse side for additional instrucho/r{/,s and qualifications. �� k�� 1
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Appticant (avneror
Taxing Disirict .��'`- / �`� Key number l legal c�escnpfi�n _ Record number
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� /1/� �n��/ �/_ � Page number 73 '1�
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Assessed value of real property as of Mortgage / Contrect indebtedness unpaid as of Is ihe applicant the sole legal or equitable
March t, current year March 1, currenl year owner? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home pC Gi.
of moAgagee or contraU seller
Address of mortgagee or contract seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
,lddress of assignee (number and sfieet, city, sfate, ZIP code)
Does applicant rnvn property in any olher I( yes, what county? I What Taxing District? Has this deduction been requested on
county in Indiana? property for curtent year? � Yes❑ No
Deduction approved in the amount of:
20 [L 20 �_ 20
Signatu�
COUNTY AUDITOR
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County Auditor
20 �� I 20 � I 20
P P
Date
certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
ient of Indiana and owner of the atorementioned propeRy on March 1, 20
Person authorized by duly executed Power o( Attorney
or by IC 6-1.1-12-.07
authorized person