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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS '
E FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
t. / Sta;e Fwm 43709 (RS I d-03)
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PrescnUed by Departmen� ot Laal Govemment Finance
fNSTRUCTIONS: T ��Fii Ma
To be filed in person or by mail with the County Auditor of the county where the property is I te� L
Filing Dates: i) Real Property: During the 12 months 6e%re May 11 0/ the year the deduction is to be elfecfive.
2) Mobile Homes assessed under IC 6• t 1-7: Between January 15 and March 2 of fh�,A,�'r the ge��n is to be eNective.
See reverse side lor additional instructions and qualifications.
� �� ��
buyer-see
Assessed value of real property
March i, wrrent year
no, what is his / her exact share of interest?
number / legal
V �'
Mort ge / ContreG indebtedness unpaid as
March 1, current year
number
Page number
Is the applicant the sole (egal �
owner? ❑ Yes 0 No
If owned wilh someone other than spouse, indicate with vlhom.
If name on record is diflerent than that of applicant, indicate below:
'ime of mortgagee or contract seller '
Address of mortgagee or contrad seller (number and reet, city, state,
Name of assignee or other owner or
assignee
mortgage
SiAiP..%�p.Clv/ni.
Does applicant own � � S- � 1��91
county in Indiana? DCawer N . • • • • • • •
.........
,��
. • ��
Card NO. � � ` ......
....._ �•;•,
Deduction approved i,� ���� dmuun� ot:
20 U G 20
�
Signature
]�� 20�� 20�
�
� County Auditor
What Taxing District?
4UDITOR
20
s ihe property in question:
O Real Property ❑ Mobile Home pC 6-7.7-�
Has this deduction been requested on
property for current year? 0 Yes ❑ No
20
20
We certify under the penalty of perjury that the above and foregoing information is irue and wrrect and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20 .
.
�2,e�-�,.�x a/q-
�e-{o,� �
Person authorized by duly executed Power of Attorney
or by IC 6-7.1-12-.07
ofauthorized person