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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FQR DEDUCTION FROM ASSESSED VALUATION wn L` Township Year
- J State Fwrt:43709 (RS / 4-03)
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P�esfnDed Ey DepartmeM of Loraf Govemmeni Finance
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INSTRUCTIONS: JF'le Mark
To be filed in person or by mail with the County Auditor of the county whe2 the property is located.�a� ,Q/�'�.
Filing Dates: 1) Real Property: Dunng the 72 months be(ore May 11 of fhe year the deduction is to b€ efleEtive U
t AUDITOR
2) Mobile Homes assessed under IC 6-1.1J: Between January 15 and March 2 o(��rQ���uchon �s to be eflective.
See 2verse side for additional instn�ctions and qualifications.
Applicant (o er or contracf buyer - see re nctions o everse 'de -�
Taxin District Key number / legal description Record number �
�/l"YwrL .,. /%{J� �y/� Q% Y r- /S�f1�Q "�_y�,` Pagenumber �� �
«�-��v �uuc3-� lr(/ w i , r o Uv � J L,v a
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
D �
If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than thaf of applicant, indicate below: Is the property in question:
� ❑ Real Property ❑ Mobile Home QC 6�1.1-�
�.rne o( moRgagee or contrect seller
Address of mortgagee or contrad seller (number and sfreet, city, state, ZIP
Name of assignee or other owner or holder of moAgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduction 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
Q P P
Signature County Auditor Date
� We certiry under the penalty of perjury that the above and toregoing information is true and correct and thal the applicants was / were
a resident of Indiana and owner of the aforementioned property on March 1, 20
i re ( w er� full m Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full resident address o applicant Address of authorized person
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