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� STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
� FOR'DEDUCTION FROM ASSESSED VALUATION 1�C!-o��n t.- t6 Ttto�1w�, hitlp Year
S J S1ata.Fwm 43709 (RS / 6-03) f1 ��� J��
',« 11
; Presuibe0 by Department of Local Gpvemment Finarice
�� � u � i z 8 2005
INSTRUCTIONS: File Mark
To ba filed in person or by mail with the County Auditor of the county where the property is located. �j�� �-
Filing Dates: 1 j Real Property: During the 12 months 6efore May 11 of fhe year the deduction is to be e/fective�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o/the'yeaP-pie=de'dtrctioq�s�fqbe�eHective.
See reverse side for additional instnictions and qualifications.
confract buyer- see
Taxing
Assessed value of real:property as of
Ma�ch t, curcent year
no, what is his /.herexact share of interest?
on revers� side)
Key number / legal description
�O`5 -000 8� - �
MoAgage / Contract indebtedness unpaid as
March 1, current year
If name on record is different than ihat of applicant, indicale betow:
'nme of mortgagee or contract sefler ��
Record number
Page number � G �
0
f Is the applicant the sole legal or equitable
owne(? �es ❑ No
Ii owned with someone other than spouse, indicate with whom.
Address of mortgagee or contraIX seller (number and street, city, state, ZIP
Name ot assignee or other owner or holder of mortgage
Address of assignee (num6er and streef, city, state, ZIP code)
Does applicant own property in any
counry in Indiana?
�
Signature
approved in lhe amouN of:
If yes, what couny7
20�_ I 20 U`1
_ �
What Taxing Di:
COUNTY AUDITOR
20 20
County Auditar
property in queslion:
zl Propeity ❑ Mobile Home
J L��y �'
3 �.7Tt m ��.�. �
D�- �!�'3 �
20
Date
20
61.1
on
INo
�/ We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
a resident of Indiana and owner of the aforementioned property on March 1, 20
iignature (owners full name) Person authorized by duiy execuled Power of Atlomey
���� M � or by IC 6-1.1-12-.07
�uil resident address of applicant Address of authorized person
3 ook �� p 1�, �r7�