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°` rt�° STATEMENT OF. MORTGAGE OR CONTRACT INDEBTEDNESS
e : FOR DEDUCTION'FROM ASSESSED VALUATION
J State Fortn 43709 (R3 / 10-00) �
�� -- . Prescribetl by State BoarE ot Taz Commissbrrers
InstrucGons for filing:
To be filed in person or by mail with the County Auditor of the county where the property is
located during the 12 months before May 11 of the year the deduction is to be effeclive. See
reverse side for additional instruclions and qualifications.
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DEC 2 8 2001
r-�aG�r� CC"-�T,� 4UpITOR
Appiicant (ow or co ract buy - s ti ns on ver e side)
Taxing Distrid Key n mber / legal description Record number Q
.
O/� _OOQ / O _ O� Page number
/
Assessed value of real property as of � Mortgage / Contrect indebtedness unpaid as of � Is the applicant th sole legal or equitable
March 1, curtent year March 1, wrrent year ownef? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If e on record is different than that of applicant, indicate below:
of mortgagee or wntracl seller
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Address of moAgagee or contrad seller (number and street, city, stat ZIP
'� c:�,r, � `� 3`l�7 � — .
Name of assignee or other owner or holder of mortgage .
Address of assignee (number and st2et, city, state, ZIP code)
Does applicant own real property in any I( yes, what county? What Taxing Distrid? . Has this deduttion been requested on
other county in Indiana? property for current year? � Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
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Sign ure County Auditor Date
�_� e certify under the penalty of perjury that the above and foregoing information is true and correct and thai the applicants was / were
ident of Indiana and owner of the aforementioned property on March 1, 20
Sig ature (owne s ful n e) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full sid nt add s of a pli L f� 6 Address of authorized person
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