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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�. J SUte Fortn 43709 (RS / 4-03)
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� PrescriDed by Department o1 Local Govemment Financa � � �
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iNSrRUCnorvs: FEB 2 �''z�`
To 6e filed in person or 6y mail with the County Auditor ol the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months belore May 11 0/ the year the deduction is to'tie eflective., ,� � ��
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0! the year the deduction is to�be eRective.
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See reverse side for additional instructions and qualifications. - GIc�S��" _': _�.70R 1
Applicant ow rcontracf u e restriction on re erse side) �
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Taxing Distrid Key number / legal description Record number �
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Assessed value of real property as of Mortgage / Contrect indebtedness unpaid as of is the applicant the sole legal or equitable
March 1, curtent year March 1, current year owneR ,[�]'Yes ❑ No
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If no, whal is his / her exacl share of interest? If owned wilh someone other than spouse, indicate with whom.
If name on record is different ihan that of applicanl, indicate below: Is thep roperty in question:
Lrl Real Property ❑ Mobile Horne (IC Cr1.1-�
�me of moAgag r contrad seller �
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Address of moAgagee or contract seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requesled on
county in Indiana? property for current year? I� Yes � No
S !� � - 3 _ /� COUNTY AUDITOR . .3�
Dedudion approved in the amount of:
zo zo� 2o n7 20 op zo 09_ Zo zo
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Signature County Auditor Dale
�/ We certify under the penalty of peryury that the above and foregoing information is true and correct and that the appliranls was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
e) Person authorized by duly executed Power oi Attomey
or by IC 6-1.1-12-.07
resident addr s of pli t Address of authorized person (