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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�'+ J Stale Fortn 43709 (RS / 4-03) - . '
�«.
� Prescn�ed by Department of loral Govemment Finance
To be� ed�'n�person or by mail with the County Auditor of the county where the propeRy is loc� 1��e ark
Filing Dates: 1) Real Property: During the 12 months 6efore May 11 0/ fhe year the deduction is to be eflective.
2) Mobiie Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the y�9Athe3le�uQ�is to 6e eNective.
See reverse side /or additional instructions and qualifications.
(owner or
Taxing
. �--� —
Asse ed value of real property as of
March 1,�current year
If no, what is his / her exact share of
on
0
/ legal description � Rewrd number
/3 -0(
Mortgage / ContraU ii
March 1, current year
�� /
If name on record is different than thaf of applicanf, indicate
mortgagee or contraIX selier
�j� /_ O O Page number A�
< <o U
ebtedness unpaid as of Is the applicant the sole legal or
� _ owneR ❑ Yes � No
If owned with someone other than spouse, indicate with whom.
Address of mortgagee or contrad selier (numbei and street, city, state, ZIP
Name of assignee or other owner or hotder of mortgage
(number and street, city, state, ZIP
Does applicant own property in any other I( yes, what county? What Taxing Distrid?
county in Indiana?
Deduction approved in ihe amount of:
20
Signature
COUNTY AUDITOR
20 _p �_ I 20 0�_ 20 I 20
� P
County Auditar
Is the property in question:
❑ Real Propeiiy ❑ Mobile Home pC 61.
Has this dedudion been
property for current year
20
Date
20
ies�ea on
Yes❑ No
certify under lhe penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
lenl of Indiana and owner of the aforementioned property on March 1, 20
o( applicant
> St
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person