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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS° -� --
' FOR OEDUCTION FROM ASSESSED VALUATION e: Ct,oun" � �To . ship Year
ti �N� t State Form 43109 (R5 / 4-03) � �- .a_../ _� ( .�
� Prescnbed by Department of Laal Govemment Finance
INSTRUCTIONS: �a �� File Mark
To be filed in person or by mail with the County Auditor ol the county where the property is locafed.
Filing Dates: 1) Real Property: During the 12 months be(ore May.11 o) the year fhe deduc�N'arS�tB�D �o �iy�.�jpITOR
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction is to be eflective.
See reverse side for additional instructions and quali�cations
(owner
ir
Assessed value of real property as of
March t, wrrent year ,
no, what is his / her exact share of interest?
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Key number / legal description Record number
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% l/� _f� � 3C� c—/'�s-� Page number O��
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Mortgage / ContraU indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owneR ❑ Yes ❑ No
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If owned with someone other than spouse, indiwte with whom.
If name on record is different than that of applicant, indicate
of mortgagee or contreIX seller
Address of mortgagee or contrad seller
city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street, city, state, ZIP code)
Is the property in question:
-•O Real Property ❑ Mobile Home (IC 61.1-�
Does applicant ov✓n property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for wrrent yeaR �] Yes ❑ No
Deduction
20 _
Signa
Drawer NO ................
Card N�'• ���' .�.Q'�
COUNTY AUDITOR
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Auditor
20
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Date
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We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
esident o! Indiana and owner of the aforementioned property on March t, 20
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Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person
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