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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
Siate Fortn 43709 (RS 14-03) ' � .
PresaiDed by Depanment ot Local Govemment Finance d�
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor of the county wAe2 the property is located. AP R 5 2005
Filing Dates: 1) Real PropeRy: During the 12 months belore May 11 of the year the deduction is to be e/%ctive.
� 2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0) the year th�-ded� ��be effective.
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See reverse side for additional instructions and quali�cations.
OIBSON COUNTY AUDITOR
or c�nfract buyef_ see restri�ns on reverse side)
Taxing
Assessed value of real property a�s of
March 1, current year
If no, what is his / her exaci share of interest?
If name on record is different ihan that
of moRgagee or contred seller
�y number / legal description Record number
Oi -�//7 . D�
� Page number � �
MoRgage / Contract indebtedness unpaid as of Is the applicant the sole legal or
March 1, current year ownef? ❑ Yes ❑ No
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indicate below:
If owned with someone other than spouse, indicate with whom.
Address ot mortgagee or contract seller (number and slreef, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street,
Does applicant own property in any
county in Indiana?
Deduction approved in ihe amount of:
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Signature
20
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state, ZIP code)
If yes, what wur,
20
Is the propeAy in question:
❑ Reai PropeAy ❑ Mobile Home (IC 61.1-�
-- '"'--� T--�--����t�n2 Has this deduction been requested on
- r cunent yea(? I� Yes O No
Drawer NO.. � � — �,� r�c �
Card NO . ..............
20 � 1 I 20
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_ County Auditor
20
20
certify under lhe penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
name)
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ent atltlf�ss of applicant
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Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
person