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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S w J State Fortn 43709 (RS / 4-03)
� P25criDed by Depertment of Laal Govemment Finance �
To 6eRfiled�lo person or 6y mail with the County Auditor ol tbe county whe2 the property ', lo � d� �' File Mark
Filing Dates: 1 j Real Property: During the 72 months before May 11 0l the year the deduction is to be effective.
2J Mobile Homes assessed under IC 6-1JJ: Between January 15 and March 2 o���yiar th���uction is to be e8ective.
See 2verse side for additional instructions and quali�cations. � „
Applicant (ySjner gr contract buye� - seeJestrictions on
Key numbe� / legal
': rUDITOR
Record number O
\ �/ � /�/�� p�//'�� �l/1 Page number �
7/ C/�l U �O «..C�
Assess d value al properry of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current ear March 1, current year owner? ❑ Yes ❑ No
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If no, what is his / her exacl share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is diHerent than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC fr1.1-7)
��e of mortgagee or contract seller �/G
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S d�'
Address of mortgagee or conlract seller (nu ber and street, city, state, ZIP
� - — --
Name of assignee or other owner or holder of mortgac �
Address of assignee (number and street, city, state, Z
Does applicant own property in any other I If yes, what
county in Indiana?
Deduction approved in the amount
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i!- � %� :
Signature
20 �/o I 20
4�1
u
County Auditor
�i1117e �4Y1 CQks/¢..r� No
Document � �3- 963�
Date io�•1�03 � �7�000. °= —
Bank 6;22�h'�4k'�o4 r3�..,�
20 O�
�
20 �
P
Date
20
We certify under the penalty ot perjury that the above and foregoing infortnation is true and conect and that the applicants was / were
=sident of Indiana and owner of the aforementioned property on March 1, 20
nat/y�1e (owners full name) Person authorized by duly executed Power ot Attomey
I Ih _. 1 (�oe.._- -^- i orbylC6-1.1-12-.07
of applicant Q IAddress of authorized person
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