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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS �
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
State Fwm 43709 (R5/4-03) �� � �. . � � - _ -
P�escriDed Dy Depanmeni of local Govemment Finance �� T�
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INSTRUCTIONS: APR `! H ZOO4 FileMark
To be filed in person or by mail with the County Auditor of the county whe�e the property is located. n
Filing Dates: 1) Real Propeiry: Dunng the 12 months before May 11 of the year the deduciion is� to�be el(ective.� �
2J Mobile Homes assessed underiC 6-L 1-7: Between January 15 and A4arch 2 of.,tf�eryear,`the dediictfon is to be eNective.
See reverse side for additional instroctions and qualifications. �✓GISSC�!1 ����� Y h�D:TC :
Applicant (ownerorcontract buyer ,se restrictions on reve� s' e)
Ta+cing Dislrid Key number legal descnption Record number D�
/� �{.��� �/ Q oD C-7 f/_fj�.� Page number
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the so�e legal or equitable
March t, wrrent year � March 1, current yeer ownef? ❑ Yes ❑ No
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 that of appiicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home QC fr1.1-�
�ame of mortgagee or contrad seller _/� �
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Address of mortgagee or coNract seller (number and street, cify, state. ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numbe� and st2et, city. state, ZIP code) �
Does applicant own property in any olh� .�/�1� P.S /� �"A� / Has this deduction been requested on
county in Indiana? �j�� 0� . property for current year?�] Yes� No
Drawer�V0 ...................
G�JI �(S /'i4-�y0 �o
Card NO. ....��.�?,.7�:.....
Deduction approved in fhe amount of: p40 a�{ — a� 2�
zo D zo_fJ� 2oO zo �$_ 2a og 2o zo
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Signature County Auditor Date
�/ We certify under the penalty of perjury that the above and foregoin3 infrnmation is true and correct and that the applicants was / were
resident of Indiana and owner of the aforemer.;ioned property on March i, 20
Signature (owners Iull name) Person authorized by duly executed Power of Attomey
�� ��`s�,ay, or by IC 6-1.1-12-.07
F resident address of applicant Address of authorized person
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