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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS -
FOR DEDUCTION FROM ASSESSED VALUATION . Coun 1—�To ns Year
�+ u� / State Fomi 43709 (RS / d-03) . , � �,,,/
� P25cnbed �y Departmem of Loral Guvemment Finance 006
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INSTRUCTIONS: �j ��ile Mark
To be filed in person or by mail with the County Auditor o/ the county where the property is /ocated. .'✓'�6�
Filing Dates: 1) Real Property: During the 12 months belore May 11 of the year the deduction is�(q�e�tfechv_g�TY ���T�R
2) Mobile Homes assessed under IC 6-1.1-7: Between January 75 and March 2 0/ tfle year the deduction is to be effective.
See reverse side for additional instructions and qualifications.
Taxing Distrid
crontracf buyer- see restrictions
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number / legal description
number
�//� /� ^ � _ �.li • Page number� / O
l�J o,[ �-c.�
Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, wrrent year owneR ❑ Yes ❑ No
If no, what is his / her exact share of interesl?
It owned with someone other than spouse, indicate with whom.
If name on record is different lhan that of appliwnl, indicate below:
�me of moRgagee or conira iler
Address of mortgagee or contract se r(number and street, city, state, ZIP
Name of assignee or other owner or holder oi mortgage
assignee (number and street, city, state, Z!P code)
Does applicant own propeAy in any other I If yes, what counry?
countyinlndiana?
Deduction approved in the amount of:
ZO h`I I 20 _{�_
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Signature
.i U/� .G
property in question:
al Pmpeity ❑ Mobile Home
4/.979.r
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I
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COUNTY AUDITOR
20 �_ 20 20
County Auditar '
1.
O"''�/`�T requested on
Iproperiy for current year? � Yes � No
20
Date
20
We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
resident address o(appfcant , � �Address oj authorized person