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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�+ �� � J Sfate Fwm 43709 (RS / 4-03)
� Prescnbed by Department of Loral Govemment Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor of the county where the property is located� ;� � �.�
Filing Dates: i) Real Property: Dunng the 12 months before May 11 of the year the deduction is fo 6e effecfive. , .
2) Mobile Homes assessed under IC 6-1.1-7: Belween January 15 and March 2 of the year �he deduction is to be eHective.
See reverse side (or additional instructions and qualifications. D E � � 5 Z��3
Appliwnt
Taxing District
Assess�d value of real property as of
March 1, current year
If no, what is his I her exact share of interest?
Key number / legal �dription ( Record number � ��
�10 C/�%-�/ �%/��� Page number �� l �
�(J �t� V 0 UJ
Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owner? ❑ Yes ❑ No
� v �.J �J
If owned with someone other than spouse, indicate with whom.
name on record is different than that of applicant, indicate
of moRgagee or contract seller
Address of mortgagee or contract seller (numbe� and
assignee or other owner or holder of mortgage
Drawer nTo..°.�-•• yya /
Card NO. '•"
��; 0�79��
Deduction approved in the amount of:
20 20�� 20 _
Signature
`e,
state, ZIP
property in
❑ Real Properry ❑ Mobtle Home (IC 61.
ihat county? I What Taxing District? Has this deduction been requested on
property for current year? � Yes ❑ No
COUNTY AUDITOR
20
Counly Auditor
20 � � 20
20
I/ We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicanis was / were
\esident of Indiana and owner of the aforementioned property on March 1, 20
full
t addressYSf applicant
a �o,r��9 s sL�.ew-t�-�0 �,.y
Person authorized by duly
or by IC 6-1.1-12•.07
of authorized person