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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATiON
�. State Fwm 43709 (RS I 4-03)
�, PresaiOetl Dy DepaNnen: of Larl Govemment Finance
INSTRUCTIONS:
To be Rled in person or by mail with the County Auditor of the county whe2 the property is located.
Filing Dates: 1) Real Property: During the 12 months 6efore May 11 oI the year the deduction is to be ef/eQtjy� � Q�nn�
2J Mobile Homes assessed under IC 6-1.1-7: Behveen January 15 and March 2 of the year the"ded ct�S ��Y be ef(ective.
See reverse side (or additional instructions and qualifrcations. ,/
�GQ ��C%
orcontract bu�Ver- see
Taxing
on ieverse side)
Key number / legal description --- - I f
G -.� �I3 - cb3 g(�-� �..�
Page number
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applica t the sole legal or equitable
March t, wrrent year March 1, current year owne(? ❑ Yes ❑ No
500 -- - -
If no, what is his / her exact share of interesl? If, owned witi . �O�-� -���
Dra�ver NO.......... ••
If name o� record is different lhan that of applicant, indicate betow: Card N�. •""'
� .
............... ; 61.1-71
mortgagee or contraIX seller
Address of mortgagee or cont�ad seller (numtfer and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, sfate, ZIP code)
Does applicant own property in any other If yes, what couniy?
county in Indiana?
Deduclion approved in the amount of:
20 �
1
Signature
Taxing Distrid? Has this dedudion been requested on
property for wrrent yea(? � Yes � No
COUNTY AUDITOR
zo P I zo P I zo I 20
County Auditor
�
Date
2�
We certify under the penalty of perjury that the above and foregoing information is lrue and corred and that the applicants was / were
residenl of Indiana and owner of the aforementioned property on Marrh 1, 20
�nature (owners lull name) Person authorized by duly executed Power of Attomey
I _ '��_. „ ,1., �_ , . "� _ � (� _ or by IC 6-1.1-12-.07
of authorized person