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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Co Township Year
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's M� / Stata Fwm 43709 (RS / 4-03)
� PrescriDed Dy Department of Local Govemment Finance
oCT 14 2003
INSTRUCTIONS: �� File M rk
To 6e filed in person or by mail with the County Auditor of the county wheie the property is located. 1�
Filing Dates: 1) Real Property: During the 12 months be%re May 11 0/ [he year the deduction is to tie e/fectiw
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2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0l the year the de uch'on; is;to„ ,� � tive.
See reverse side for additional instructions and qualifications.
Applicanl (owner or contract 6uyer - see
Assessed value of real property as of
March 1, curtent year
If no, what is his / her exact
name on record is different
on reverse side)
� � ��
Key number / legal description
interest?
Record num r
OU i - /( q �
Page number
Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owneR �-Yes ❑ No
9�00� I
If owned wilh someone other than spouse, indicate with whom.
of applicant, indicate
sthe property
I�Real Property ❑ Mobile Home pC &1.1-i
�me of mortgagee or conVaIX seller
S�3 �r,,�,
Address of mortgagee or contrad seller (number and st2et, city, state, ZIP __
Name of assignee or other owner or holder oi mortgage �Q (.� �,�7 Z �b � OBtl • B d
5 Eh/aaQ �
Address of assignee (number and street, city, state, ZIP code) - �', n �
� (.�1�I�-� ��
Does applicant own property in any other If yes, what county? Vb„e, ,,..., uested on
.., -'--
county in Indiana? property for wrrent yearr u Yes� No
`i� �I L/„ n <9 i COUNTY AUDITOR
Deduction approved in the amount of:
20
Signature
F��11/i���Z�7
20 Q
�
County Audftor
20 I)li 20_
I
Date
20
We certify under the penalty of perjury that the above and foregoing information is lrue and correct and that the applicants was / were
resident of Indiana and owner of the aforemenlioned property on March 1, 20
Person authorized by duty executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person