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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VAIUATION Coun Township Year
� �� / State Fwm 43709 (RS / 4-03) � � �
� Presai�ed Dy Depanment o1 Lxal Govemment Finance
INSTRUCTIONS: �UN ��`� �6
To be filed in person or 6y mail �vith the County Auditor of tAe county whe�e the property is located. �-�y,,
Frling Dates: 1) Real Property: During the 12 montAs before May 11 01 the year the deduction is fo be eRect/vet ��
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o(the ye�g�Bt�$�e�����s�g���ctive.
See ieverse side (or additional instnrctions and qualifications.
Dislrid
buyer - see restrictions on reverse
Key number / legal description � Record number
I � Page number ^ � �
� a�4-ooiao-oo .s
Assessed valu f real property as of Mortgage / Contrad indebtedness unpaid as of Is lhe applicant ihe sole legal or equitable
March 1, current year March 1, current year owner? ❑ Yes ❑ No
Ii �io, 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 ihat of applicanl, indicate below: Is lhe property in question:
_ ❑ Real ProceM ❑ Mobile Home (IC G1.1-71
oi mortgagee or contrad seller
Address of mortgagee or conlrad seller (number and
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any olher I If �ac,, what couniy?
county in Indiana?
Dedudion approved in the amount of:
20
Signature
state, ZIP
What 7axing Distrid? Has this dedudion been requested on
property for current yearl � Yes � No
COUNTY AUDITOR
20 �� 20 __� 20 20
� P
County Auditor
20
Date
20
� We certify under the penalty of peryury that the above and foregoing information is true and corred and ihat the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
fi3O name)
Person authorized by duly executed Power of Attomey
or by IC 6-1.7-12-.07
Address of authorized person