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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES�
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (R5 / a-03)
PrescnDed by Department of Local Govemment Finance
INSTRUCTIONS:
To 6e filed in person or by mail with the County Auditor of fhe county whe2 the property is located.11 �,�
Filing Dates: 1) Real Property: Dunng the 12 months before May 11 0! the year the deduction is td�Ge�'�e/fectrv��U3
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 20/ the year the deduction is to�be e(fective.
See reverse side Ior additional instnictions and qualifications. �„�j ��
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' C:3SJIQ C:�.::�: Y n:;J:-C3 :
(owner 4r cd�tract 6uyer -
Taxing
Assessed value of real property as of
March 1, wrrent year
If no, what is his / her exact share of interest?
Key number / leg�al description � Record number
OO/—_Q/a� 7 �� Pagenumber
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MoRgage / Contred indebtedness unpaid as of Is the applicant the sole legal r equitable
March 1, current year owneR ❑ Yes ❑ No
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If owned with someone other than spouse, indicate with whom.
If name on record is differeni than ihat of applicant,
of mortgagee or conlrad seller
Address ot moAgagee or contrad seller (number and stieet, city, state, ZIP
Name of assignee or olher owner or holder of mortgage
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Dra�ver NO.Q.�..—...�i ��5�
Dc :ounty? What Taxing District?
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Card NO . .....................
COUNTY AUDITOR
Deduction approved in the amounl of:
20Q�
2005 20�� 20S]
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County Auditor
20 ��
s lhe property in queslion:
❑ Real Property ❑ Mobile Home (IC Cr1.1-�
Has lhis deduction been requesled on
property for current year? � Yes ❑ No
20 �_ 20
P
Date
� We certify under the penalty of perjury that the above and foregoing information is true and correc[ and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly exewted Power of Attorney
or by IC 6-1.1-12-.07
resident address of applicant Address of authorized person
�i22 �d �x 37/ /r,�.l� .TNd. �7��