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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION �oMMMun Township Year
� J State Fortn 43709 (RS / 4-03) � �
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P25cribed by Department ot Local Govemment Finance
wsrRUCriows: MAR � 8 2��,7Ma�
To be filed in person or by mail with the CountyAuditor of the county where lhe propeRy is located.�
Filing Dates: 1) Real Property: During the 12 months belore May 11 0/ the year the deduction is to be eNe?ctiye'�
2J Mo6ile Homes assessed under IC 6-1.1-7: Befween January 15 and March 2mt�ge�yearGt�N d�dpUDoTORto be effective.
See reverse side for additional instructions and qualifications.
Applicant ( erorcontracf buyer- see restnctions on reverse side)
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Taxing Dislrid Key number / legal description
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Assessed value of real property as of MoRgage / ContraG indebtedness unpaid as
March 1, wrrent year March 1, wrrent year
(9� �Dv
Ii no, what is his / her exact snare of
If name on record is different lhan that of applicant, indicate below:
of mortgagee or contract seiler
of mortgagee or contrad seller
of assignee or other owner or
Record number
Page number
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Is the applicant the sole legal or
owner? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
and street, city, state, ZIP
of mortgage
s the property in quesfion:
❑ Real Prop�ty p Mobile Home QC Cr1_1
Address of assignee (num6er and st2et, city, state, ZIP code) �/ ��� �
Does applicant own property in any ofher If yes, what county? \ /� �� requested on
countyinlndiana? `Yn���e aOV�' y/�/ ?�Yes�No
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COUNTY AUDITOR •
20
Signature
in the amouni ot:
20�_
r
20� 20 20
Y
r County Auditor
20
Date
20
v v � 3/ 8/v �
certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
ent of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
II resideN aAdress of applicant Address of authorized person
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