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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun wn ' Year
S�� J State Fortn 43709 (RS / 4-03) O�
� PreSCnDed Dy Depanmeni cf LcKal Govemment Finarxe Q
2 2006
INSTRUCTIONS: File Mark
To 6e filed in person or 6y mail with the CountyAuditor o(the county where the property is located. �a� ��
Filing Dates: 1) Real Property: During the 12 months be%re May 11 0/ the year the deduction is to be e ective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the yea����6ciiU' FiLfi'to/bee{(e�tive.
See reverse side /or additional instructions and qual�cations.
or contract buyer
Assessed value of real property as of
March 1, curtent year
If oo, what is his / her exact share of interesl?
an
Record number
� - � �p o �
�//— �a _� Page number � b �
Mortgage / Conlrad indebtedness unpaid as of Is the applipni the sole legal or equitable
March 1, current year owner? ❑ Yes ❑ No
C/
If owned with someone olher than spouse, indicate with whom.
If name on record is diHerent than that of applicant, indicate below:
I
of mortgagee or contrad selier (number and st2et,
Name of assignee or other owner or holder of mortgage
ZIP
s the property in question:
❑ Real Property ❑ Mobile Hm�e QC 57.1
Address of assignee (numberand street, city, state, ZIP code)
Does appliwnt own property in any other If ves. what county? y�a� 7; )e �n, re� ��-e l S 7na N �ed on
county in Indiana? ' • • • • ; ❑ No
Dra���er \0 ...............
�oo� _ bbas
— Card NO. •••••••
COUNTYAUDITO �p UUd.00 '
Dedudion approved in fhe amount of:
20 � % 20 �_
P �
Signature
20 _�J`�_ 20 20
�
County Auditor
20
Date
20
We certify under the penalty of peryury Ihat the above and foregoing infortnation is lrue and corred and ihat the applicanis was / were
�sideni of Indiana and owner of the aforementioned property on March 1, 20
ture (owners fidl name)
Tenn i %r ffi.
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Address of authorized person