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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Township Year
� ! Stata Fwm 43709 (R5/ 4-03)
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PrescriEed by DepaRmeM o1 Local Govemment Finance
JAN1$��
INSTRUCTIONS: Fi e a
To 6e filed in person or 6y mail with the County Auditor of the counry where fhe property is located. �
Filing Dates: 1) Rea/ Property: Dunng the 12 months belore May 11 0! the year the deduction is to 6e efl"EcTIJe �•�+�!
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ th�,j68U���t�r�G� to 6e effective.
UDITOR
See reverse side !or additional instructions and qualifications.
Tazing
/ ,/
I
see
A96essed value of real property as of
March 1, wrrenl year
If no, what is his / her exad share of
ieverse
Key number / legal description Record number o O�
/�n .CU _ �/Q (� � � Page number �� ��
a..�. i
MoAgage / ContraIX indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curcent year owneR ❑ Yes ❑ No
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If owned with someone other fhan spouse, indicate with whom.
If name on record is different than lhat of applicant, indicale below:
mortgagee or contrad seller
Address of mortgagee or cont�act seller (number and street, city,
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP code)
Does applicant own property in any other I If yes, what county? I What Tauing Distrid?
county in Indiana? _
Deduction approved
20
1
Signature
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amoun
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County Auditor
s the property in question:
❑ Real Property ❑ Mobile Home pC 61.1-�
Has this dedudion been requested on
propeRy for wrrent yeaf? � Yes � No
20
Date
20
We certity under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
residenl of Indiana and owner of the aforementioned property on March 1, 20
(ull name)
applicant
Person authorized by duly exewted Power of Attomey
or by IC 6-1.1-12-.07
of authorized person