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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES -r ��
FOR DEDUCTION FROM ASSESSED VALUATION Co5' T n ip Year
�. w� ♦ State Fwm 43709 (RS / 4-03) �
� P2soib¢d yy Department of Laal Govemment Finance n O��oo�
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INSTRUCTIONS: '-77i6� ��ile Mark
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To be filed in person or 6y mail with the County Auditor o! the county where the propeRy is located. Q �
Filing Dates: 1J Real Property: During the 12 months belore May 11 o/fhe year the deduction ��jy1Z"Cd�'tiC�?Y AUDITOR
2) Mobile Nomes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is fo be effeclive.
See reverse side for additional instructions and qualifications.
Applicant (o ne� or contract buyer - see restrictions on reverse side)
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Taxing Districl Key number / legal description Rewrd numb r
l� L��,o9-/a3-�0/8�0�7 �GU�
�-- Page number
- 5- � 3�
Assessed value of real pro rty as of Mortgage / Contrac indebtedness unpaid as of Is the applicant t e sole legal or equitable
March t, cunent year March 1, current year owner? es ❑ No
�l J�Od
Ii no, what is his / her exact share of inleresl? If owned with someone other than spouse, indicate with wfiom.
I( name on record is different than that of applicant, indicate below: I$the� properiy in question:
L1 Real Proper(y ❑ Mobile Home (IC 61.1-�
�me of mortgagee or contraG seller
3
Address of mortgagee or contracl seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this dedudion been requested on
county in Indiana? property for wrrent yeaR �] Yes � No
COUNTY AUDITOR
Dedudion approved in the amount of:
20 20 _Q� 20 �� 20 20 20 20
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Signature County Auditor Date
We certiy under the penaity of perjury thaf ihe above and foregoing information is true and corred and that the applicants was / were
a resident of Indiana and owner of the aforementioned property on March 1, 20
Signa re wners Iull name) Person auihorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
Ful resident addre of applicant Address of authorized person
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