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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Ye:
�'+ �� � J State Fwm 43709 (R514-03)
PresaiOeG by Department of Loral Govemment Finance
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INSTRUCTIONS: File Mark
To 6e filed in person or by mail with the County Auditor o/ the county whe2 the property is focated.
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to'�1 g gflective.
2) Mobile Homes assessed under IC 6-1.1-7: Belween January 15 and March 2 of the year the�e��n is to be eflective.
See reverse side for additional instructions and qualifications � �//
Applicant (owner or
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Assessed value of real property as of
March 1, curzent year
If no, what is his / her exact share of
name on rewrd is
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Key number / legal des tion � Record numb�c �(�
�0� � .3�6�-� �
Page number O/�
Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curre9t,ygarD _'��pQJppQ, owner? ❑ Yes ❑ No
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If owned with someone other than spouse, indicate with whom.
,me of mortgagee or contract seller �/�
Address of mortgagee or contred seller (number and s et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
A, ZIP code)
_ Dra��erNO.c�:?.^.••�•°• ��
Dc , t counry? Whal Taxing DisWct?
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CardNO . .....................
$o��UJ t�00�/
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20 � 20 � 20 U(c
�/�.t�0e4� 1 �
Signature
COUNTY AUDITOR
20 ��
County Auditor
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s the property in question:
❑ Real Property ❑ Mobile Hwne (IC 61.
Has this deduction been requested on
property for current year? � Yes� No
20 Q]_ 20
P
Date
We certify under the penalty of perjury ihat the above and foregoing infortnation is true and correct and that the applicants was / were
' ent of Indiana and owner of the aforementioned property on March 1, 20
nature (o ners (lyl namG)G�� j Person authorized by duty executed Power of Attomey
�Q� � or by IC 6-1.1-12-.07
person