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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
b� J State fortn 43709 (RS / 4-03)
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� PiesaibeA by Department of Local Govemment Finance ;' ��' i� �� '�—'�
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INSTRUCTIONS: �U� �,7 Z�Ui� Mark
To 6e filed in person or by mail with the County Auditor ol the county wAere the property is located. �
Filing Dates: 1) Real Property: During the 12 mon[hs before May 11 of the year the deductionis to be effective.�
2) Mo6ile Homes assessed under IC 6-1J-7: Between January 15 and March 2,0/ the year tlie de�d.u�ctio�ro��is� to�de elfective.
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See reverse side for additional instructions and qualifications. ?3SON 6, C'.-: r.,�_,'C:. .
Applicant (owner or contract y- s e rest
Taxing Distrid
Assess value ofre roperty as
March 1, wrrent yea
If no, what is his / her exad share of inlerest?
side)
Key number / legal
Mortgage / Contred ir
March 1,�{yugnt year
If name on record is different than that of applicani, indicate below:
'3me of moAgagee or contrad seller
Address of moAgagee or contrad seller umber and stre t, city, s
Name of assignee or other owner or holder of mortgage
(number and street, city, sfate, ZIP code)
Does applicant own propeRy in any other I If yes, what wunty?
county in Indiana?
Deduction approved in the amount of:
20 20Q�_ 20 �;'
� �
SignaWre
Rewrd number
l,/�_� IPagenumber
i��7
as
owneR
��C
1 the sole legal or
❑ Yes ❑ No
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If owned with someone other than spouse, indicate wilh whom.
; the property
❑ Real Proper
��.�.J
ZIP
❑ Mobile Home (IC 61.1
What Taxing Distric[? Has this dedudion been requested on
property for wrrent year? � Yes ❑ No
COUNTY AUDITOR
20
County Auditor
20 � 20 _
�
Date
20
We certify under the penalty of perjury that the above and foregoing infortnation is true and correct and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by du�y execuled Power of Attorney
or by IC 6-1.1-12-.07
ient address of applicant IAddress of authorized person
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