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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
: ! State Fwm 43I09 (R5 / 4-03)
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� Presaibed by Department ot Local Govemment Finarke ({� �4, �� i� � h
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INSTRUCTIONS: .IULFile Mar�o�
To be filed in person or 6y mail with the County Auditor of the county where the property is located.
Filing Dafes: 1) Real Property: Dunng the 12 months before May 11 of the year the deduction is to be effective. ��
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0l the year the deducHon is fo be ef(ective.
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See reverse side /or additional instructions and qualifications. � Gi3SOtt COl'' "`�.-"G;
contract b�yer - see
�
Taxing
on reverse
number / legal description
number
�n �. - .5�� G8"
O/ I_O Q� rage num�er
7' �3
Assessed value of real property as of Mortgage / ContraG indebtedness unpaid as of Is lhe applicant the� oie legal or equitable
March 1, current year March 1, current year owneR [��'S'es ❑ No
�o � .Sad'
If no, what is his / her exact share of
If name on record is different ihan that of applicant, indicate below:
mortgagee or conlrad seller
If owned with someoneplher than spouse, indicate with whom.
Real
Address o( mortgagee or contract seller (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage --('�
Address of assignee (numberand street, city, state, ZIP cod� Dra{Ver �io �� v
o��o� ..................
Does applicant own property in any other If yes, what count Ca rd Np S� �� �'S �
county in Indiana?
. � �yJC�� ..........
Deduction approved
20
Signature
C�/��OUNTY AUDITOR
amount of:
20 �y� I 20 �_ I 20 _01
County Auditor
20 � 20 �
�
❑ Mobile Home (IC 61.
ddion been requested on
:urrent yeaRO Yes❑ No
20
/ We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned propeRy on March 1, 20
$igpat (owners full na e
x �
Full y dent address of applic
\ . ., _,. . � rtc_ -
Person authorized by duly executed Power of Attomey
o� by ic s-,.,-,2-.0�
of authorized person