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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
b-«� ♦ State Fwm 43709 (RS / 4-03)
%� PresaibeC by Department of Local Govemment Finance
INSTRUCTIONS: [fF I� e M�ark�l fL.� [� 11
To be filed in person or by mail witb the Counry Auditor of the county where the property is located. � ��L,J liJ 1L..J%�
Filing Dates: 1) Real Property: During the 12 montAs before May 11 01 the year the deduction is fo be elfective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction,)s,te b� eite�
See reverse side for additional instructions and quali(cations.
Applicant (owner or contract
Taxing
V��1.1�(T,J
Assessed value of real property as of
March 1, curcent year
If no, what is his / her exact share of inlerest?
on
Key number / legal descriplion � Record
��7-���%����r
Mortgage / Conlrad indebtedness unpaid as of
March 1, current year
( �4��0
If name on record is different than lhat of appiicant,
of mortgagee or contract seller
Address of mortgagee or contract seller (number and st2et, dty,
Name of assignee or other owner or holder of mortgage
Address of assignee (num6erand sGeet, city, sfate, ZIP
Does applicant own property in any other If yes, what wunty?
county in Indiana?
Deduction approved in the amounf of:
20
Signature
�l�fi'�
1/
���
Is lhe applicant the sole legal or equitable
ownef? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
What Taxing Distrid?
COUNTY AUDITOR
�1i-�
T I �
County Auditor
❑ Real
❑ Mobile Hame (IC 61.
Has this dedudion been requested on
property for current yeaR � Yes � No
20 � 20
P
Date
certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
�
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person