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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S � / State Fwm 43709 (RS / 4-03) � � �?
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PrascnDeO by Dapartment of Local Govemment Financa H
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�TRUCTIONS: OCT �.� �0�3
� be �led in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1J Real Property: During fhe 12 montbs before May 11 01 the year the deduction is to �effective� � �
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the ea tig�8d c�f��'o�isA�o e'Ge echve.
See reverse side for add\ bnal instructions and qualifrcations.
buyer-
reverse
legal description
0/�- �?�� �
Assessed value of real property as of Mortgage / Contract ii
March 1, current year March 1, currenl year
If no, what is his / her exact share of interest?
If name on rewrd is different than that of applicant, indicate below:
mortgagee or conlracl
ot mortgagee or contrad
and street, city,
or other owner or holder of mortgage
Address of assignee (number and street, ciry, state, ZIP code)
Does applicant ovm property in any other If yes, what
county in Indiana?
zo
Signature
approved in the amount
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COl
Record number �O,O
Page number /
unpaid as of I Is the applicant the sole legal or
owner? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
❑ Real
❑ Mobile Home (IC E1.1
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20 �
County Auditor
non oeen requestea on
reni year? ❑ Yes� No
20 �� � 20 �� � 20
I/ We certify under the penalry of perjury that the above and foregoing information is true and corzect and that lhe applicants was / were
a resident of Indiana and owner of ihe aforementioned property on March 1, 20
(owners full �ame)
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�01 5 � s} s7. QW4✓ISY1 � ��� �
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person