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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION
S M� J State Fwm 43709 (RS / 4-03) ., . . - - . . .
� Prescnbed Gy Depanment of Local Govemmem Finance -
Coun Township Year
INSTRUCTIONS: ' gg--�� e
-r To be filed in person or 6y mail with the County Audifor o( the county where the property is located. ���
Filing Dates: 1) Real�Property: Dunng the 12 months before May 11 0/ the year the deduciion is to 6e e echv �� �"
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2,of the year the deduction is o e e ective.
See reverse side for additional instructions and qualiTcations.
(owner or contract
�See resmcho on rpre e yde)
V�• CJ
Key number / IeA e
� r� �
MAY 0 9 2006
Rewrd number
��^'O � I Page number � Q
Assessed value of reai propeity as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, currenf year March 1, current year . owner? ❑ Yes ❑ No �
CQ 000 Q�
If no, what is his / her exact share of inlerest? If owned with someone other than spouse, indicate with whom.
If name on record is diHerent than that ot applicant, indicate below: Is the property in question:
�
of mortgagee or contract seller
of mortgagee or contrad seiler (number and street, city, state,
assignee or other owner or holder of moRgage
of assignee (numberand street, city, sfate, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District?
county in Indiana?
Deduction approved in the amount of:
20
Signature
20�(�
COUNTY AUDITOR
20 �_ 20 20
P
Counry Auditor
❑ Real Property ❑ Modle Home (IC 61.1-�
-`I O�W
Has this dedudion been requesled on
property for current year?Q Yes� No
20
Date
20
We certify under the penalty of perjury that the above and foregoing information is true and correct and that lhe applicants was / were
�esident of Indiana and owner of the aforementioned property on March 1, 20
c
Person authorized by duiy executed Power o( Attomey
or by IC 6-1.1-12-.07
authorized person