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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�`• FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
State Fortn 43709 (RS / a-03)
� Prescd0e0 Gy Department ot Local Govemment Finance
INSTRUCTIONS: � , � � +File Mark ; 7 -�
To be filed in person or by mail with the County Auditor o/ the county where the propeRy is located. �� � t,� � I� ��"� � ��
Filing Dates: 1) Real Property: Dunng the 12 months 6efore May 11 0l the year the deduction is to be eflective. � —J
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the de�� t�on �'s to be eHective.
See reverse side for additional instructions and qualifications. ^ l�U04
Applican wnerorcontractbuyer-s
.�cQ4 a� d ,
Taxing Distrid
�� , v/
Assessed value of real property as of
March 1, wrrent year
If no, what is his ! her exacl snare of i
on rever� side)
' ^': .;./-r ....;.�•-.�
Key number / legal description � Record number �
Q(� �— Q�Ja 9� Page number O�
I
Mortgage ! Contract indebtedness unpaid as of is the applicani th ole legal or equitable
March 1, current year ownef? �s ❑ No
� c� a
If owned with someone other lhan spouse, indicate with whom.
name on record is different than thal of applicant, indicate below:
of mortgagee or contract seller
Address of mortgagee or contract selier (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Properly ❑ Mobile Home QC 61.1-n
/�. li. e Y
��L
Address of assignee (numbe� and st2et, city, state, ZIP code) � ����
ia�f.6B�o . ..+ Ui ��Y��
Does applicant own propeRy in any other If yes, what county? What 7 ^� ^ � a� __.:� � requested on
county in Indiana? /`L`. - l7d�I _r.:��y tor current year? O Yes❑ No
v
COUNTY AUDITOR
Deduction approved in the amounl of:
20
Signature
��1���>:' � � ��
—�
County Auditor
20
20
certify under the penalty of perjury that the above and foregoing information is true and correcl and that the applicants was / were
ient of Indiana and owner of the aforementioned property on March 1, 20
Iull name)
applicant
Person authorized by duty executed Power of Atlomey
or by IC 6-1.1-12-.07
person