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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
��w� ! State Fwm 43709 (RS / 4�03) , � 777��� T �—�.�
� PrwcriDetl by Depanment of Local Gtivemment Finance �� (i — t� !1 1``
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INSTRUCTIONS: J�Fii�e rv�ark 2004
To 6e filed in person or by mail with the CountyAuditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year fhe deduction is to 6e effec ivt e.
2J Mobile Homes assessed under lC 6-1.1-7: Between January 15 and March 2 of the yearlhe�deductiony Jto be.effe h e.
See reverse side for additional instructions and quali�cations. �J �!=S�;; CO7;<� v:,�pITC- ,
Applicanl (owner or contracl6uyer- see restrictions on reverse side)
Taxing Dislrict ey number / legal description Rewrd number
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P � � ^ Q Page number
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the appliwnt the sole legal or equitable
March 7, curcent year March 1, current year owneR �T'es � No
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If no, what is his 1 her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
eal Property ❑ Mobile Home (IC 61.1-�
�'ame of mortgegee or coniract seller
1.�.�� 'C cAJ.l_s n� s�_ e-. �
Address of moRgagee or contract seller (numher and street, city. state. ZIP � �
Name of assignee or other owner or holder of mortgage –
Address of assignee (numberand street, city, state, ZIP code) DI'a���er 1�T�, ��, ,- .�� f$
Does applicant own property in any other i; yes, �ti•hat counly? r :en requested on
Card \O
. ..................... =ar?n Yes� No
county in Indiana? I
COUN i Y AUDITOR
Deduction approved in the amount of:
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Signature County Auditor Dale .
�I/ We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
' ature (own rs full nam ) Person authorized by duty executed Power of Attomey
� or by IC 6-1.1-12-.07
Full resident and ress o'f/a/pplicant / Address of authorized person
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