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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
" ' FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
� � State FOrtn 43709 (R4 / 10.01)
� m.
PrescribeA hy DeDaMienl W Laal Gavemment Finance
INSTRUCTIONS: � gile u ark � �
To 6e filed in person or by mail with the County Auditor o/ the county where the property is located. �i �L ���
Filing Dates: 1) Real Property: During the 12 months before May 11 ot the year the deduction is to be effective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Befween January 15 and March 31 0( the year the ded��n �'� fb �ctive.
See reverse side for additional instnictions and qualifrcations. �` ,/) _ „
orcontract
Uons an rever side)
Key number / legal description
Rewrd
Page number
Assessed value of real property as of Mo� age / Contrad indebtedness unpaid as of Is the applicanf tfie sble legal or equitable
March t, current year March 1, current year owneR ❑ Yes ❑ No
�
I( no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
- - � - /. � Q��P
If name on ecord is different than that of applicant, indicate betow: Is the propeRy in quesiion:
� ❑ Real Property ❑ Mobile Home QC E1.1-�
of mortgagee or contract seller
Address of mortgagee or wnVad seller (number and street,
or other owner or holder of mortgage
of assignee (number and street, city, state, ZIP code)
ZIP
Dces applipnt own property in any other If yes, what county? What Taxing Distrid?
counly in Indiana?
COUNTY AUDITOR
20
Signature
in the amount of:
20 20 20 O
P
County Auditor
o �- 3, Sy
ao�� - ►��s
Has this dedudion been requested on
properly for current yeaf? � Yes� No
20 �_ 20 � 20
P p
Date
/ We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and lhat the applicants was / were
i resident of Indiana and owner of the aforemenlioned property on March 1, 20
i n e(owners full na ) Person authorized by duly executed Power of Attomey
/f -- � --- � �/ /Qi� - or by 1C 6-1.1-12-.07
person