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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
State Fam 43709 (R5 / 4-03)
Prescribed Oy Department of Loral Gtivemment Finance �� � ,� � j"��
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INSTRUCTIONS: Fi�e Mark
To be filed in person or 6y mail with the CounryAuditor of fAe county where the property is locat�� N 12 2004
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to be e/fective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Marc3�'2 0/ the. yea� the tleduction is�o be effective.
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See reverse side /or additional instructions and quali(cations. i° GBSGN COUV i � r.uUiTOR I
Applica wne�orcontract er- see restnctions on reverse side)
Taxing Dislrid Key number / legal description Record number ��
1 � /(� / _ A1�S?(�j�lY� Page number � O� � �
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Assessed value of real property s of MoAgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, cunent year owneR ❑ Yes ❑ No
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Ii no, what is his / her exact share of interest? If owned with someone other than spouse, indicate wilh whom.
If name on record is different than thal of applicant, indicate below: Is the property in question:
� Real Property ❑ Mobife Home QC 61.1-�
�me of moRgagee or contracl seller �
Address of mortgagee or contrad seller (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand s6eet, city, state, ZlPcode)
Does applipnt own property in any other If yes, what county? What Taxing District? Has this dedudion been requested on
county in Indiana? property for current year? � Yes ❑ No
COUNTY AUDITOR
DeducGon approved in the amounf of:
20 O� 20 ��0 20 20 �g_ 20 � 9_ 20 20
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Signature County Auditor Date
� We certify under the penalty of perjury that the above and foregoing information is trve and corred and that the applicants was / were
resideni oi t and owner of the aforemenlioned property on March 1, 20
Signature ners I ame) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
u reside t a ress of applican ddress of authorized person
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