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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNFcc
FOR DEDUCTION FROM ASSESSED VALUATION
State Fofrt143709 (R4 / 10-01) . � �
Presaibed by Departmen� W Laal Govemment Finaixe
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INSTRUCTIONS:
To 6e filed in person or 6y mail with the County Auditor o/ the county where the pro rty
Filing Dafes: 1) Real Property: During lhe 12 months before May 11 of the year the deduction is tq 6e�f(�'�'ve.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Mard� �iif fiie`�y�at'flTe deduction is to be effective.
See reverse side (or additional instructions and qualifications_ �� � /( n /�
Applicant
Tauing
contract buye�- see restrictions on reverse
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description Record number � �0�
/� O / �. .�i0 �s_DD Page number / , SS
(J cr� (% e�
Asse sed value oi real property as o Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March ¢1 pcu.rr�enl,�year 3� 50 � owneR ❑ Yes ❑ No
� "1 � �--'� 1 .
If no, what is his / her exact snare of interest? If owned with someone other than spouse, indicate with whom.
name on record is diflerent than that of applicant, indicate below:
of mortgagee or contract seller �
Address of mortgagee or conVact seller (number and street, city, state, ZIP
Name of assignee or other owner or holder oi mortgage
of assignee (number and street, city, sfate, ZIP code)
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Does applipnt own property in any other I If yes, what county? What Taxing Distrid?
counry in Indiana?
20
Signature
the amount of:
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Pp'AQo �9
COUNTY AUDITOR
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County Auditor
Has lhis dedudion been requested on
property for curtent yeaf? � Yes ❑ No
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/ We certify under the penalty of perjury that the above and foregoing informalion is true and corred and thal lhe applicants was / were
� resident of Indiana and owner of the aforementioned property on March 1, 20
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Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person