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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' ' FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
�s / State Fortn 43709 (RS I 4-03)
�«
� Prescnbetl by Department of Loca� Govemment Finance
�
INSTRUCTIONS: � � �ile M� , t
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 months before May 11 0/ the year the deduction is to be effective: ��—_/ -
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January i5 and March 2 0/ the year the de�vur� o is to be eHective.
JU 1 [� Z004
See reverse side for additional instructions and qualiTcations. �
(ownerorcont ct r-see
Assessed value of real property aS of
March 1, curcent year
Key number / legal description
v � O/ 11 O°7�4 io Page number � �
((, V
Mortgage / Contract indebtedness unpaid as of Is the applicant the sole le al or
March 1, �it Year owne(? ❑ Yes ❑ No
If no, what is his / her exact share of interest?
If name on record is different than lhat
o! mortgagee or contrad
Address o( mortgagee or contract
Name of assignee or other owner or
of assignee (number and st�eet,
indicate below:
cify.
mortgage
�tate, ZIP code)
Does applicant own property in any other I if y=s, �h�tiat county?
county in Indiana? �
Deduction approved in the amount of:
20
SignaWre
20 � �r
owned with someone other �han spouse, indicale with whom.
Is the
❑ Real Property ❑ Modle Home OC 61.1
l`d;�at Taxing Distrid? Has this deduction been requested on
property for wrrent year?� Yes� No
COUN i `( AUDITOR '
20 �� 20 _Q� 20 0� 20
� P
County Auditor Dat
20
/ We certify under the penalty of perjury that the above and foregoing information is true and corred and lhat the applicants was / were
resident of Indiana and owr�.y�r of the aforemen;ioned property on March 1, 20
full
Person auihorized by duiy execuled Power o( Aftorney
or by IC 6-1.1-12-.07
of authorized person