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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�. / State Fwm 43709 (RS I 4-03)
�w �� PresaiEed by Department of Local Govemment Finance �
�/
�,
Coun Township Year
INSTRUCTIONS: File Mark
To 6e filed in person or by mail with the Counry Auditor of the county where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 months be(ore May 11 of the year the deduction is to be ef/ective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction is to be effective.
See reverse side for additional instructions and qualifrcations.
Applicant (owne�or
Tauing
Assessed value ofreal
March 1, current year
Ii no, whal is his / her exact
restnctions on �rs� side)
number / legal
Record number �
� v /Y� � /� �/� �%O_iy1 Page number
l�� E/Ol / L-CJ
as of � Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, cunent year ownef? ❑ Yes ❑ No
��._)c_� ��
e of interest? owned wifh someone other lhan spouse, indicate with whom.
If name on record is different lhan that of applicant, indicate below:
�me of mortgagee or contraIX seller n D/��1 /�
A / I
Address of mortgagee or contract seller (nu er and stieet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
assignee (numberand st2et, city, state, ZIP code) a
.3_a
Does applicant own property in any olher I If yes, what county?
county in Indiana?
20
approved in lhe amouni of:
s the property in question:
❑ Real Property ❑ Mobile Home (IC 61.
--
/i� /J� fjJ��f��w�� a
/�Y�t,G-�` � I �'a2GS, Cr;'r�• «
COUN O�'����
20 � I 20 6' 20 �
Ij
County Auditor
� � .
ion been requested on
ent year?�] Yes� No
20 ` 20
Date
We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
full
applicant
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07 _
authorized person