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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S' / Siate Form 43709 (RS / 4-03)
,� ,� � �i , �, Y�
PresaiDed by Department of Loral Govemment Finance —
INSTRUCTIONS: AUG F�I�.M�3
To be filed in person or by mail with fhe County Auditor of [he county where the property is focated.
Filing Dates: 1) Real Property: During the 12 months befo2 May 11 0/ the year the deduction is to b�lfective. �� n
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o/the year-the.de`duction!is to 6e e(fective.
See reverse side for additional instructions and qualifications.
i� ciason courlrr AuoiTe�
Applicant (grf/ner or contract
Assessed value of real propeAy as of
March 1, cunent year
�strictions on re e side)
Key number / legal d scription
�� - 019 `�-�
Mortgage / Contracl indebtedness unpaid as
March 1, current year
If no, whaf is his / her exacl share of interest?
If name on record is diHerent than thaf of applicant,
of moRgagee or contract seiler
below:
Record number �
Page number ,�, ,
Is the applicant the sole legal or equitable
ownef? ❑ Yes ❑ No
owned with someone other than spouse, indicate with whom.
of mortgagee or contrad seller (number and st2et, city, state, ZIP
assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP
Does applicant own property in any other If yes, what county? What Taxin
county in Indiana?
20
Signature
COUNTY AUDITOR
approved in the amouni of:
20 Q,� I 20 Q� � 20
Counry Audilor
20 �
s the property in questian:
❑ Real Property ❑ Mobile Home pC 61.1-�
��3- /�>�9
Drawer NO ..............
.....
,,,, on
CSCd �10 . ................ ' I No
20�x 20
P
Date
' We certify under the penalty of perjury fhat the above and foregoing infortnation is true and corred and that the applicanls was / were
resideni of Indiana and owner o the aforementioned property on March 1, 20
�nat te wners /�e) Person authorized by duly executed Power of Attomey
� � ^ _ ��� � or by IC 6-1.1-12-.07
address of
2 �� .3�s
of authorized person