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STATEMENT OF MORTGAGE OR CONTRACT IN
FOR DEDUCTION FROM ASSESSED VALUATIC
Stata Fartn 43709 (RS / 4-03)
PrascnEed by Department of Loral Govemment Finance
INSTRUCTIONS: DEC 1� �^e�
To be filed in person or by mail with the Counry Auditor ol the county where the property is Ixated.
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to be e/Iective. � ( � � G
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0l tbe yea� the'deduction/is to'6e'effective.
See reverse side for additional instructions and quali�cations. �G�3¢Op� C''%i'rt i'' h���TOn �
Applicant (owner or contract y- e strictions on rse side)
Taxing ' rict Key number / legal description Record numb '� C��
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� / � _0��70 1(y� Page number
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, cunent year March 1, current year owner? ❑� ❑ No
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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 diHerent than that of applicant, indicate below: Is the p erty in queslion:
❑ eal Pro�erty ❑ Mobile Home (IC 61.1-7)
� of mortgagee or contract seller /� ,I,
� !��-C£n.-K� .�� �., . � 9 - 13 3 �'
Address of mortgagee or contract seller (number and street, city, state, ZIP � •
Name of assignee or other owner or holder of mortgage Dra�r'2i v0, �� —
............
Address of assignee (num6er and street, ciry, state, ZIP code) �j 5 q�
Card NO. ....
.................
aa, ico. �
Does applicant own property in any other If yes, what county? What Ta �� �^_ ted on
county in Indiana? a_ "� sO No
COUNTY AUDITOR
Deduction approved in the amount of:
20 � zo o,� zo 20 �_ zo �_ 2o D q zo
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Signature Counry Auditor Date
I I We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
sident of Indiana and owner of the aforementioned property on March t, 20
Si - wn s full name) Person authorized by duly executed Power of Attomey
� or by IC 6-1.1-12-.07
u/aenty ddr�s of�pl���� Address of authorized person
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