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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coua - Tq_ hip Year
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S J State Fortn 43709 (RS / 4-03J
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� P2scriEed �y Department of local Govemment Finance
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INSTRUCTIONS: File Mark
To 6e filed in person or 6y mail with the CountyAuditor of the counry where the property is located. `�j �
Filing Dates: 1J Real Property: Dunng the 12 months be%re May 11 0/ the year the deduction is to be e�ciive. �
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 c�t��eaCCl�deducliunYS�fo be eBective.
See reverse side for additional insfructions and qualifications.
(owner or contract
Taxing Distrid
see re:
Assessed value of real propeiiy as of
March 1, current year
If �io, what is his / her exact share of interest?
name on record is diHereni than that
oi mortgagee or contract
mortgagee or contrect seller
on
Key numher / legal description Record number
��'',�_�_,j0°-c�3.6�a-cu� Pagenumber
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MoAgage / Contrad indebtedness unpaid as of Is the applicant �he sole legal or equitabie
March 1, current year ownef? [y4e5 ❑ No
1
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If owned with someone other than spouse, indicate with'whom.
indicate below:
assignee or other owner or holder of moAgage
city. state, ZIP
Address of assignee (number and streel; city, state, ZIP code)
Does applicant own property in any olher � If �.a.._ ��hat county?
county in Indiana? I
Deduction approved in the amount of:
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Signature
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Taxii
COUNTY AUDITOR
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County Auditor
Properly ❑ Mohile Home (IC 61.1-�
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Date
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We ceKify under ihe penalty of pequry thaf tha above and foreaoino informatipn is true and corred and ihat ihe applicants was / were
'esioent of Indiana and owner of fhe aforementioned property on March 1, 20
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� Person authorized by duly executed Power of Nftomey
or by IC 6-t.t-12-.07
un�m aaaress or appucant Address of authonzed person
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