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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
S / Stata Fortn 43709 (RS I 4-03)
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� PrescnEed Gy Department of �ocal Govemment Finance
Coun Township Year -
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INSTRUCTIONS: ANH 2F�le�k
To be fi/ed in person or by mail with the Counry Auditor of the county where the property is locatec� ��U4
Filing Dates: 1) Real Property: During the 12 mon[hs before May 11 of the year the deduction is t�� eBec`e� O
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 oftlie�yearYhe:d�ductLron is b 6' e ctive.
See reverse side for additional instructions and qual�cations. J�� !. ��f' ',� t Uu1Tp^
Applicant
Taxing Dislrid
- see
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Assessed value of real property as of
March 1, wrrent year
no, what is his / her exact share of interesl?
on reverse side)
Key number / legal description Record number D I/
��,
D�/–�g–(f0 Pagenumber /�/��
Y
MoRgage / Contrad indebtedness unpaid as of Is ihe applicant the sole legal or equitable
March 1, wrrent year owner? ❑ Yes ❑ No
/��, �
If owned with someone other than spouse, indicate with whom.
If name on record is diNerent than that of applicant, indicate below:
moAgagee or contract seller
Address of mortgagee or contract seller (number and street, city, state, ZIP
Name of assignee or other owner or
Address of assignee (num6er
�r of mortgage
^�` "' ' code)
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�we►'ND'••........� ••"�G,�
Dra �i/ , r �
`f'
_ Card Np. .
Dedi
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Signature
_..�vunt of:
20 U � 20 �
� �
�
vnry? I What Taxing Distrid?
COUNTY AUDITOR
20 �� 20 ��
� /
County Auditor
s the property in question:
❑ Real Property � ❑ Mobile Home ({C
Has this dedudion been requested on
property for current year?� Yes❑ No
20
Dale
20
' We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
name)
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
O, IAddress of authorized person
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