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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
`. � ♦ State Fwm 43709 (R5/4-03) , T. , -.—� -� �
� PrescriEed by DepaM1ment ot Laal Govemment Finance � � � �� ��
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INSTRUCTIONS: F E Q,File t_�r a3�704
To be �led in person or by mail wifh the County Auditor of the county where the property is located.
Filing Dafes: 1) Real Property: Dunng fhe 12 months be%re May 11 of the year the deducfion is ro 6e e efl cfive. /�
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the yeardhe_deduct omrs to.be•eR cti e.
See reverse side for additional instructions and qualifications. �� GI3SOti C'CUt�Tt ;.v�J:TCi� i
Assessed value of real property as of
March 1, current year
If no, what is his / her exad share of
reslrictions on�v�rse side)
<ey number / legal description
�/- ��� �-��
MoAgage / Contrad indebtedness
March 1, curreM year
If name on record is different lhan ihat of applicanl, indicate
mortgagee or contrad seller
of mortgagee or contreIX seller (number and street, city,
Name of assignee or other owner or holder oi mortgage
DrawerNO ................... 'code>
DOe: Card NO. . � .�3. ��a�� :ounry?
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Deduction approved in the amouni of:
20 D �
Signature
20 n!c
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Record number� �
Page number /Ga
as of Is the applicant the sole legal or equitable
owner? ❑ Yes ❑ No
owned with someone other than spouse, indicate with whom.
What Taxing Distrid?
COUNTY AUDITOR
�al'.i � �
P I p
County Auditor
s the property in question:
❑ Real PmceM ❑ Mobile Home
Has this dedudion been requested on
property for wrrent yeaR � Yes � No
20
Date
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We certify under the penalty of perjury lhat the above and foregoing information is true and correct and lhat ihe applicants was / were
�esident of Indiana and owner of the aforementioned property on March 1, 20
full name)
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Person authorized by duly exewted Power of Attomey
or by IC 6-1.1-12-.07
asident address of applicant IAddress of authorized person
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