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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION Coun' H' 'i Township-- � Year
. «• ! State Fwm 43709 (RS / 4-03) � 1,� :� i !
PrescriGed by Depanment of Local Govemment Finance , ���
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INSTRUCTIONS: � File Maric
To be filed in person or by mail with the County Auditor of the county where the property is located.�� ,�� Y�- . (/n
Filing Dates: 1J Real Property: Dunng the 12 months be(ore May 11 of the year the deduction is to`be;eltective:- `�!- "� —�%`�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 ot the year the deduction is to be effective.
See reverse side for additional instructions and quali�cations.
Applicant (owner or contr/act`6uyer-/�ee restrictions on reverse side)
11 o W`� 1-� m � � u ca. �y
Taxing Distrid Key number / legal description Record number
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�Z I e�� � �� � � a� OD Page number
Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owne(? ❑ Yes ❑ No
3 � 7 �1 7
If no, what is his / her exacl share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
L9'F%al Property ❑ Mobile Hortie (IC 61.1-�
�me of mortgagee or contracl seller
G.ln 9C ii�9c"� c. e �f V i t�S
Address of mortgagee or coniract sei r(n mber and st2et, city, state, ZIP
, 0.�- ��OD
Name oi assignee or other owner or holder of mortgage
Address of assignee (number and street, crty, state, ZIP code)
Does applicant own property in any other If yes, what counry? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for current yeaR � Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 �_ 20 �_ 20 20 20
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Signature County Auditor Date
�We certify under the penalty of perjury that the above and foregoing information is lrue and corred and that ihe applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20 -
Sig�ure (owne�/ull name) Person authorized by duty execuled Power of Attomey
or by IC 6-1.1-12-.07
Full resident ddress of applicanl \ �.., ` Address of authorized person
07 �J e e l�Zl�-1��5 y'76