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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
+��� i State Fortn 43709 (R5l a-03) '
Prescnbed Cy Department ot Laal Govemment Finarwe
I�NSTRUCTIONS: � u � r� ��
7 ) File Mark
To be filed in person or by mail with the Counry Auditor of the county where the property i5�located. �� �� �
Filing Dates: 1) Real Property: During fhe 12 months before May 11 0/ the year the deduciion is to be eflective.
2J Mobile Homes assessed under IC 6-1.1-7: 6etween January 15 and March 2 of,i�ie�Yea� the�ai�bction is to be effective.
See reverse slde lor a0tlitional instructions and quali�cations. // �
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Applicant (owne� or contract buy - ee resMctions on rev e sid u=°"' "-`•' '"' "• """ '
Taxing Di 'ct y number / legal description Record number �
D/�_ DD � P/_ ,('ti\ Page number
`T � (7 �/��
Assesse alue of real property as of Mortgage / Contract indebtedness unpaid as of Is lhe applicant the sole legal or equitab�e
March 1, current year March 1, current year ownef? ❑ Yes ❑ No
D
Ii no, what is his / her exad 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: Is the property in question:
❑ Real Property ❑ Mobile Hmie QC 61.1-�
�me of mortgagee or contract seller �
Address of mortgagee or contraIX seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? � property for wrrent year?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amounl of:
20 � 20 � 20 �� 20 �_ 20 20 20
� V � /
SignaWre County Auditor Date
'/ We certi(y under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
��esident of Indiana and owner of the aforementioned property on March 1, 20
'gnature (owne/s fuil name) Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
II resident dress of applicant Address of authorized person
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