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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS �
' FOR DEDUCTION FROM ASSESSED VALUATION ou n ip Y ar
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: «. ! State Form 43709 (R5l 4-03) . . . - . , OV ^
PrescriDed �y Department of Loral Gdvemment Finance A PR p 20�� ���
INSTRUCTIONS: p�lc� �Ig'Mark
To be filed in person or by mail with the County Auditor o/ the county where the property is Iocate,���S�N CA�NTY � �7qp
Filrng Dates: 1J Real Property: During the 12 months befo2 May 11 0/ the year the deduction is to e elfectiv
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0! the year fhe deduction is to be effective.
See reverse side for additional instructions and quali�cations. �
- see
Taxing
Assessed vatue of real property as of
March 1, current year
no, whal is his / her exact share of
on reverse side)
Key number / legal description %( Rewrd number �/
, / v .����
�//_/�/��,CL��� Pagenumber
liC/ /
MoRgage / Contrad indebtedness unpaid as of is the applicant lhe sote legal or equitable
March 1, current year owner? ❑ Yes ❑ No
If name on record is different than that of applicanl, indicate
�e of mortgagee or contract seller /� �
owned with someone other than spouse, indicate wilh whom.
Address ot mortgagee or contrad seller (number an�s,/reet, city, state, ZIP
Name of assignee or other owner or holder of moRgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant avn property in any other I If yes, what county?
county in Indiana?
Deduction approved in the amount of:
20 f') I
P
Signature
� a :
�
Is the property in question:
❑ Real PropeAy ❑ Mobile Hane pC 61.1-�
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DrawerNO ...................
CardNO . .....................
�OeJ�-3 ���
What Taxing Distrid?
COUNTY AUDITOR
20 � 20 20
Counry Auditor
Has this dedudion been requesled on
propeRy for current year? 0 Yes � No
20
20
certify under the penalty of perjury that the above and foregoing information is true and corred and thal the applicants was / were
len�.aftrr�iana and owner of the aforementioned property on March 1, 20
(ull
�a w
Person authorized by duty executed Power of Attomey
or by IC 6-1.1-12-.07
ofauthorized person