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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S � State Fortn 43709 (RS / 4-03)
�w
� P�esaiDed Ey Department ot Local Guvemment Finance
INSTRUCTIONS: Sti 1F'�IQ�(�
To be filed in person or by mail wfth the County Auditor of the county where the property is located. "
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to ef%ctive.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Maich 2 0! th r t e �c '� to �tive.
See reverse side foradditional insfructions and qualifications. ��eSCPd COUhiY a��DITOR
Applicant (owner
Taxing District�
Asses d vatue �
March 1, wrrent
Ii no, what is his
coo noct buye -��est 'p�tion�s o,re� rse�
Q 1G�
Key nu ber / legal de
P�oPertY
her exacl share of interest?
J...J�_] � l �., S I
Mortgage / Contrad ir
March 1, current year
OS
Record number O'
Page number 1 Q^�
oC ��
as of Is the applicant the sole legal or equitable
owneR ❑ � � No
If owned with someone other than spouse, indicate with whom.
If name on record is different than that ot applicant, indicate below:
����.�, � r
me of mortgagee or coniract seller �
� �1 f� �
Address of mortgagee or contraIX seller (number and st2et, city, state, ZIP
s(t'h�e property in question:
�al PropeAy ❑ Mobile Home QC 61.1-�
Name of assignee or other owner or holder of mortgage �/�� ---- -
Address of assignee (num6erand street, ciry, state, ZIP code) ��
Does applicant own property in any other If yes, what county? �A
county in Indiana? � / _ � n �
7
�p, o �
couNTV,au �/
Deduction approved in the amount of:
/
20�� 20�(�
Signature
20
County Auditor
20 �
�en requesled on
�ar? � Yes ❑ No
20 � 20
P
Dale
We certify under the penalty of perjury that lhe above and foregoing infortnation is true and correct and lhat the applicants was / were
residenl of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by iiuly executed Power of Attorney
or by IC 6-1.1-12-.07
of aulhorized person