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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES�
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (RS / 4-03)
PrescnDeO Ey Department ot Loral Govemmeni Finance
INS7RUCTIONS:
To be filed in person or by mail with the County Auditor o/ the county where the property is
Filing Dates: 1) Real Property: During the 12 months before May 11 o/the yearthe deduction is to 6e e�c#'Ivel 9 Z��3
2) Mobile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 0/ the year the deduction is to be effective.
See reverse side for additional instructions and quali�cations. � � /n/
/ _ GIB/� TY AUDITOR 1
Applicant (owner�rEontract buyer-
TaYing Dislrid
Key number / legal descriplion � Rewrd number
� � O � /� � .7 / � _� Page number � , !�"yS
�l_J �-� �(..J
Assessed value o eal property o Mortgage / Contrad indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, wrtent year March 1, currenl year owneR ❑ Yes ❑ No
Ii no, what is his / her exad
If name on record is different than that of applicant, indicate below:
- -•-^rv+�.ad.seller
Drawer � .. r and
NO.:..�- � ��5'0
iortgage
Card NO . .....................
If owned with someone other than spouse, indicate with whom.
�3 ,
city, state, ZIP
state, ZIP code)
Is the property in question:
❑ Real Property ❑ Mobile Home QC Fr1.1-�
Does applicant own property in any o[ne� „ y es, what county? What Taxing District? Has this dedudion been requested on
county in Indiana? property for current year? � Yes � No
Deduction approved in the amounl of:
20
Signature
COUNTY AUDITOR
�O.'iZ�Tll��i7
County Audilor
20 � I 20 � I 20
We certify under the penalty of perjury that the above and foregoing information is true and correcl and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
name)
resident address of applicant
� R � � o � �L1 fF i�rr�ti<�te�v
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
of authorized person