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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
�'+ �w� ! State Fwm 43709 (RS I 4-03) � � . .
� PrescdEed �y Department of Local Govemmeni Finance � '
INSTRUCTIONS: � � ile M� �
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1J Real Property: During the 12 mon[hs belore May 11 of lhe year the deduction is to be e!/ective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the ��e�ti$n � ts,pe,effective.
See 2verse side for additional instnictions and qualiTcations.
CUUb
(owner or contract
on reverse
Key number
OIB80N
number
�
v�� � ..
4 O r O��/� O v Page number �7
�
Assess value of real property as of Mortgage / Contracl indebtedness unpaid as of Is ihe applicant th ole legal or equitable
March 1, current year March 1, current year owneR Yes ❑ No
O�a�'. �
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 that of applicant, indicate below:
of mortgagee or contrad seller
Address of mortgagee orcontract seller (number and street, city,
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP
Does applicant own property in any other I If yes, what couniy?
county ir Indiana?
Dedudion approved in the amount of:
20
V
Signature _
20_08_
�
ZIP
What Taxing District?
COUNTY AUDITOR
20 v-i 20 20
/
County Auditor
ie property
Real Pro�erty ❑ Mobile Home (IC 61.
Has this dedudion been requested on
property for current year? � Yes❑ No
20
20
� We certify under the penalty of perjury that ihe above and foregoing information is true and correct and that lhe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
yFrJesltlent address of applicant
Q- �- l F�lH �� ��0 F�•
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
of authorized person
� � � ✓