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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' ' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�.� / State Form 43709 (R5 / 4-03) .
� �«. . . - . . - .
PresaiCetl 6y Department of Local Govemment Finance
INSTRUCTIONS: � � �FifB'iVla�
To be �led in person or 6y mail with the County Auditor of the county whe�e the property is locate 1LJ �J'
Filing Dates: 1) Real Property: Dunng the 12 months before May-11 0l the year the deduction is to be eHective.
, 2) Mobile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 o(the year ��1�edLc�r�� 6e ef(ective.
See ieverse side for additional instructions and quali�cations.
Taxing
see restricti ns on reverse side) �
Key numb legal description
number
QQ" _� 36a_�� IPagenumber Q oG Jr
`1 O /
Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant ihe sole legal or equitable
MarcFi 1, airrent year . March 1, current year ownef? ❑ Yes ❑ No
l0 J V� V
If no, what is his / her exact share of interest? Ii owned with someone other than spouse, indicate with whom.
If name on record is diHerent than lhat of applicant, indicate befow: Is the property in question:
mortgagee or contrad seller � � � � �
Address oi mortgagee or contract seller (number and street, city, state, ZIP
Name of assignee or
Address
owner or holderof mortgage
(number and street, city, state, ZIP
Does applic`ant own property in any other if yes, what county? What Taxing District?
wunty in Indiana?
COUNTY AUDITOR
Deduction approved in the amount of:
20 �_
SignaWre
20
20 � 20 20
County Auditor
� Real Properly � Mobile Home (IC 61.
Has this dedudion been requested on
property for wrrent year?� Yes❑ No
20
Zi7
We certify under the penalty of perjury that the above and foregoing information is true and corred and thal the applicants was / were
�e�ident of Indiana and owner of the aforementioned propeRy on March 1, 20
(ull name)
address of applicant
�
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-72-.07
of authorized person