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� STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
, �`+ / Stata Fwm 43709 (RS / 4-03)
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� Piesui0ed by Depertment of Local Govemment Finance
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INSTRUCTIONS: � � t' '�FileY
To be filed in person or by mail with the County Auditor o/ the county w6ere the property is locgted. �, l�-J "`J
Filing Dates: 1 J Real Property: Dunng the 12 months be%re May 11 0/ the year the deduction is to 6e effective. •/ ��
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0l the year the iledt��Cr 3 is to be effective.
See 2verse side for addiGonal instructions and quali�cations. / i(���✓�
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Applicant (�er or contract buyer - see resMctions on reverse sid� J '4 � i3S0�+'�-"' ��
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Taxing District Key number / legal description Record numbe�
O(,�' 1 —�' �� � Page number
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Assessed val of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the le legal or equitable
March 1, current year March 1, curcent year owner? es ❑ No
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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 difierent than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC E1.1-7)
ie of mortgagee or contract seller _ — ^
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Address of mortgagee or contract seller (number and st2e , city, state, ZIP - ��� O
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Name of assignee or other owner or holder of mortgage _. —
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Address of assignee (numbe� and street, ciry, state, ZIP code) � �'
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Does applicant own property in any other If yes, what county? I 0 3�/ G S-7 �ted on
counry in Indiana? `�� � _.. — ..;s� No
COUNTV AUDITOR
DeducGon approved in the amount of:
20 20 � 20 [`� ' 20 �2 20 O� 20 � 20
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Signature County Auditor Date
�We certify under the penalry of perjury that the above and foregoing information is true and corcect and that the applicants was / were
asident of Indiana and owner of the aforementioned property on March 1, 20
Signa ure (owner's full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Fu resi ent ddress o appl nt Address of authorized person
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