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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�+ �M / State fortn 43709 (R5 / 4-03)
P�ascnDed by Department of Local Govemment Finance
�TRUCTIONS:
0 6e filed in person or by mail with the County Auditor o) the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to be eBect� �.0
2 2003
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0l the yIe/ar the deduction is to 6e effect/iv,e.
See reverse side for additional instructions and qualifications. y, l' . �,�, j�,:-1, .-,. ��L�y
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P.pplicant
ii
contract buye� - see restrictions on reverse
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Assessed value of real property as of
March 1, curtent year
If no, what is his / her exact share
U�lo- i-( rl 7' a
If name on rewrd is diHerent
Name of mortg gee or contr�
ress of mortgagee or co
number / legal description
Mortgage / Contrecl ir
March 1, curtent year
indicate below:
Page number
unpaid as of Is the applicant�ole legal or
owner? s ❑ No
If owned with someone other than spouse, indicate wiih whom.
seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
street, city, state, ZIP code)
Is
Does applicant own property in any other If yes, what county? What Taxing �
county in Indiana?
ueducnon approvea in the amount ot:
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Signature
�
COUNTY AUDITOR
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1
County Auditor
❑ Mobile Home (IC E1.1-7)
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Drawer Np,,,� �
Card `jp ��f�
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T I 1� I
Date
I/ We certiTy under the penalty of perjury that the above and foregoing infortnation is true and correct and tnat the applicants was / were
a residen of Indiana and owner of the aforementioned property on March 1, 20
,�nature ownels full name) 1 n Person authorized by duly executed Power of Attorney
� /1 d a,... 1�) \ R f�. _ 1/n . orbylC6-1.1-12-.07
person