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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
's J State Fwrt: 43709 (RS I 4-03)
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� P2scri�ed by Deparimeni of Local Govemment Finance
INSTRUCTIONS: � � File ar �
To be filed in person or by mail with the County Auditor of the county where the property is located. g�
Filing Dates: 1) Real Property: Dunng the 12 months befo2 May 11 0l the year the deduction is ro be effec i.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year th u i i e e(fective.
See reverse side for additional instructions and qualifications. � S�� �����
Applicant (owner or contract buyer -
Taxin nd
� ` �
Assessed value of real property a of
March 1, wrrent year
no, what is his / her exact share
Y
Key number / legal description Record number O�
QQ� _ Q �Q � � Page number � � �
Mortgage / Contrad indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, curre�� owneR ❑ Yes ❑ No
QQ �
If name on record is different lhan lhat of appiicanl, indicate below:
of moAgagee or contreIX seiler
�
If owned with someone other than spouse, indicate wilh whom.
Address of mortgagee or contract selier (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand stieef, city, state, ZIP code)
Is the property
❑ Real Property ❑ Mobile Hmie (IC 61.
Does applicant own property in any other If yes, what county? I What Taxing District? Has this dedudion been requested on
county in Indiana? property for wrrent year?� Yes❑ No
Deduction approved in the amount of:
20 �� 20 05
O/.A/�w�.v �
COUNTY AUDITOR
20
County Auditor
20 �� 20 _
� Date
20
/ We certify under the penalty of perjury thal the above and foregoing infortnation is irue and corred and that the applicants was ! were
resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Atlomey
or by IC 6-1.1-12-.07
of authorized person