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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
: J SUte Fortn 43709 (RS / 4-03)
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� PrescriDed by Department ot Local Govemment Finance
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INSTRUCTIONS: �� ` �� �' Fil�ilark
To be filed in person or by mail with the County Auditor o! the county where the property is located.� °�11� 13"1
Filing Dates: � Real Property: Dunng the 12 months 6e%re May 11 of fhe� ar the deduction is to � e��e, �,�nn4
2 Mobile Homes assessed under IC 6-1.1-7: Between Janua 15 and Ma�ch 2 o/the ea/t� eii �6Nf5 to be eHective.
See reverse side for additional instiuctions and qual�cations. � ///�
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Applicant,�nwne or confract 6uye � e restricfio n reverse side) ,,
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Taxing Di� Key number / Iegal description Record number
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�,^ I O �� � ^ � Page number
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant t sole legal or equitable
March 1, current year March 1, current year owne(? Yes ❑ No
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If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that ot applicant, indicate below: Is the,property in question:
L1{Real Property ❑ Mobile Home QC fr1.1-�
�ame of moRgagee or contract seller
Address oi mortgagee or contract seller (number and street, city, state, ZIP
Name of assignee or olher owner or t
Drawer NO..D� ���3'y'
Address of assignee (num6er and str "' • • • • •' • • • • •/
Does applipnt own property in any ot Card NO._ ...: :..� ............. :trict? Has this deduction been requested on
county in Indiana? � • property for current yeaf?� Yes❑ No
COUNTY AUDITOR
Deduction approved in fhe amount of:
20 20 O(p 20 20 ��' 20 �� 20 20
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Signature County Audilor Date
�/ We certify under the penalty of perjury that the above and foregoing information is true and correcl and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners (ull name) Person authorized by duly executed Power of Attomey
uor by IC 6-7.1-12-.07
F II resident address of applicant Address of authorized person
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