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4
STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (RS I 4-03)
Presai6etl by Department of Loral Gtivemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the CountyAuditor o) the county where the property is located. �� O
Filing Dates: 1) Real Property: During the 12 months belore May 11 0l the year the deduction is to 6e eflecAJ'e� 1 Z�03
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the y,/ear the d�edu/ction is to be effective.
See reverse side for additional instructions and qualifications. ,�.c,��, �S J�� /% /n/
�� GI3$CIJ COUt�TY qiJDI7Gn 1
(owner or conf�acf buyer- see restrictions on reverse
(\ c� •
Taxing Dislrid
Assessed value of real property as of
March 1, curreni year
Ii no, what is his / her exact share of interest?
Key number / legal
number
number
MoRgage / Contrad indebtedness unpaid as of Is the ai
March 1, current year owneR
8��00
If name on record is different than that of applicant,
of moRgagee or conlrad seller
c me soie iegai or
�s ❑ No
If owned with someone olher than spouse, indicate with whom.
Address df mortgagee or conirad seller (number and stieet, city, state, ZIf
Name of assignee or other owner or holder of mortgage
Address of assignee (num6erand street, city, state, ZIP
❑ Mobile Home (IC 61.1
Dra�ti�er NO.. Q. � ; ;% .3 � �
Card NO . .....................
Does applicant own property in any other I If yes, what wunty? I What Taxing District? Has this dedudion been requested on
county in Indiana? property for current year?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amouni of:
r' �`I / ` � � ' � �. �
County Audifor
20 �_ 20 0 i 20
P
Date
We certify under the penalty of perjury lhat the above and foregoing information is true and corred and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners (ull name)
Person authorized by duty executed Power of Attorney
or by IC 6-1.1-12-.07
Y�, 4> o IAddress ot authorized person