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��' � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�� FOR DEDUCTION FROM ASSESSED VALUATION n hip Year
� ! S�ele Fwm 43709 (R6 / 5-OGl
Aesaihed by Depanment of Loral Govemmem Finance
MAY 1
INSTRUCTIONS: File Mark
To be Fled in person or by mail with the County Audito� o! fhe county where the propeRy is Ixated..� �
Filing Dates: 1) Real Property: Dunng the 12 months before June 11 0/ the year fhe deduction is to be efleetive.
2) Mobile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 G��i����gyf�lBJSk��iiT�s�o be effective.
See reverse side for additional instrucfions and quaf�cations.
Applicant (owner or contract buyer - see stnctio n reverse side)
Taxing District Key number / legal desuiption Record number O�- a y y
� � Page number
Assessed value of real property as of Mortgage / Con act inde tednes's unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owner? �Yes � No
o �oa
If no, what is his / her exact share of interest'? If owned with someone other than spouse, indicate with whom.
I( name on record is difterent than that of applicant, indicate below: Is the property in question:
Property � Mobile Flome QC 61.1-7)
�e oi mortgagee �ntract sel�
Address oi mortgagee or contract seller (number and reet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and stieet, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for wrrent year? ❑ Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20� 20�_ 20 O 20 20 20 20
� �
Signature Counry Auditor Date
i/ We certify under the penalty of perjury that the above and toregoing infortnation is W e and correct and that the applicants was / were
s�dent of Indiana and owner of the aTorementioned property on March 1, 20
,yn ture (owners full name) � Person authorized by duly executed Power of Attomey
• � or by IC 6-1.1-12-.07
Full resident address of applicant Address of authorized person �'
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