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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S / State Fortn 43709 (RS / 4-03)
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Piasaibetl by Department of Local Gtivemment Finance ( "'"� .
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To beR� d�ln�person or by mail with the County Auditor of the county where the property is IocaFeF B � 4 2OO4Fi1e Madc
Filing Dates: 1) Real Property: During the 12 montbs 6efore May 11 0/ Me year the deduction is to be eflecfive.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0! the. year the deduction is to 6e effective.
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See reverse side for additional instructions and qualifications. ' G".9SOC! C'OUtt i•r „i rr,,� `�
Applicant (owner or
Taxing Distrid
Assessed value of real property
March 1, curcent year
If no, what is his / her exad
see restS !`-u-J L�n ieve e sideh �
J 7�
Key number / legal description
of
interest?
�O�( —��b/ `�U(� Pagenumber —` ����
l'�
MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or E
March 1, current year 3 O-D i� p owneR ❑ Yes ❑ No
aS�OZS
If owned with someone other lhan spouse, indicate with whom.
name on record is different ihan ihat of applicant,
of mortgagee or contrad seller
below:
Address of mortgagee or contracl seller (number and street, city,
Name of assignee or other owner or holder of mortgage
of assignee (numberand st2et, city, state,
Does applipnt own property in any other If yes, what county?
county in Indiana?
2007
P
Signature
approved in the amount of:
20Qf�
�
ZIP
What Taxing Distrid?
COUNTY AUDITOR
20 l.�
P
County Auditor
Is the property in question:
❑ Real Property ❑ Mobile Home QC 61.1-
Has this dedudion been requested on
propeAy for current yeaRQ Yes� No
20 �� I 20
0
�
We certify under the penalty of peryury that 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
duly executed Power of Attomey
or by IC 6-1.1-12-.07
IAddress of authorized person
a ��.�. ��