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� STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
♦ J State Fwm 43709 (RS / 4-03) . �
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� PresaiEed Dy Departmem ot Local Govemment Finance �
INSTRUCTIONS: Fil
To be filed in person or by mail with the County Auditor of the county where the property is located. F E,B 1 a�
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is to be eflective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 ot the year thg„Sfae�duc��o be effective.
See reverse side /or additional instn�ctions and qualifrcations. `��� (/
..,..� rn�INTY AUDITOR
li�oa�,�- - -
ApplicaM ner or contract yer see cti on revers ide)
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Taxing islri Key number / legal descriptio Record number /
Page number �
00��/%- �e
Assessed lue oi real property as of Mortgage / ConlraU indebtedness unpaid as of Is the applica th ole legal or equitable
March 1, current year March 1, current year owner? Yes ❑ No
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 lhat of applicant, indicate below: Is he erty in queslion:
Real Property ❑ Mobile Home (IC 61_t-�
�me of mortgagee or rect seller
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Address of mortgagee or contract seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and st2et, city, state, ZIP code) /� �
Q��� I�i� F ��O b'
Does appticant own property in any olher If yes, what counry? What Taxing District? Has this dedudion been requested on
county in Indiana? property for wrrent year?� YesO No
COUNTY AUDITOR
Deduction approved in the amount of:
20 /i � 20 O% 20 �� 20 �� 20 20 20
�
Signature County Auditor Date
' I We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
� resident of Indiana and owner of the aforementio�ed property on March 1, 20
ature (owners full na e) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
resident a ress of applica Address of authorized person