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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (R5 / 4-03)
PrasrribeC by Oepartment of Loral Govemment Finance
Coun Township Year
INSTRUCTIONS: File Mark
To 6e filed in person or by mail with the County Auditor of [he county whe�e the propeRy is located. �' �
Filing Dates: 1) Real Property: During the 12 months befo2 May 11 0/ the year the deduction rs to be eHective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the de tio t� ch
See reverse side Ior additional instnictions and qualifications.
Applicant (owneror
Taxing Distrid
Assessed value of real
March 1, current year
number / legal description
Q �_ O / �%y% � Page number
� Q /o� —
''t r i 7 2003 �
3
as of Mortgage / Contred indebtedness unpaid as of I Is the applicant ifie sole legal or equitable
March 1, current year ownef? ❑ Yes ❑ No
// �OOC�
If no, what is his / her exacl share of interest?
If name on record is diHerent than that of applicant, indicate below:
If owned with someone other than spouse, indicate with whom.
❑ Real Property ❑ Mobile Home (IC 61.
of mortgagee or contraIX seller
Address of mortgagee or contracl seller (number and st2et, city, state,
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st�eet, city, state, ZIP code)
Does applipnt own property in any other If yes, what county? What Taxing District? Has this dedudion been requested on
county in Indiana? property for curcent yea�? O YesO No
Deduclion approved
,r i � •
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Signature
in the amount of:
20 �J 20 ��
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COUNTY AUDITOR
20 O '/
County Auditor
20 �_
20 �_
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Date
20
We certify under the penalty of perjury lhat the above and foregoing information is true and corred and that lhe applicants was / were
�esident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly execuled Power of Attorney
or by IC 6-1.1-12-.07
ofauthorized person