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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
'•,w � �/ State Fom:43709 (R5/4-03)
� PrescnDed�6y Departmem o! Local Govemmeni Finance
Coun • Township Year
INSTRUCTIONS: File Mark
To 6e liled in person or by mail with the County Auditor of the county whe�e the property is located.
Filing Dates: 1) Rea/ Property: During fhe 12 months before May 11 0/ the year the deduction is to be effective.
Yg :.�. w�.
2) Mobile Homes assessed under !C 6-1.1-7: 8etween January 15 and March 2 0/ the yea� fh�ded� on� ��
See reverse side Ior additional insWCtions and qualifications. � �
(owne� or contrac(
Taxing
Assessed value of real property as of
March 1, wrtent year
If no, vthat is his
exact share ofinierest?
number / legal
Record
� Page number .- �
MoAgage / Contract indebtedness unpaid as
March 1, current year
/�� � 6 C�
S �_
Is the applicant ihe sole legal or equitable
owneR ❑ Yes ❑ No
If owned wifh someone other than spouse, indicate with whom.
If name on record is difterent than that of applicant, indicate below:
,3me of mortgagee or wnhact seller /\,�
Cr
Address of mortgagee or contract seiler (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
of assignee (numbe� and street, city, state, ZIP code)
Does applicant_own property in any other I If yes, what county? What Taxing District?
county in Indiana?
COUNTY AUDITOR
)eduction.approved in the amounl of:
20 -01 20 ,_� � 20 09 20
� � P
Signature
County Auditor
�
s the property in question:
� Real Property ❑ Mobile Home pC 6-1.
Has this dedudion been requested on
property for wrrent year? �] Yes � No
20
Dale
20
' We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
resident of Indiana and owner of the aforemenlioned property on March 1, 20
(owners full n
� N
:n address of
�
Person authorized by duly executed Power of Attomey
or by IC 6-1.7-12-.07
Address ofauthorized person