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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
�+ �� I State Fwm 43709 (RS / 4-03)
� PrespiCed by Departmem of Local Govemment Finance
I
�TRUCTIONS: � � � � �
6e �led in person or by mail with the Counry Auditor of the county where the property is loc
Filing Dates: 1 J Real Property: Dunng the 12 months 6e%re May 11 01 the year the deduction i to be e8 tive.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is to be efFecfive.
See reverse side Ior additional instructions and qual�cations. � � T 2 3 2��3
Applicant (owner
Tazing
Key number % iegal description I Record numb�
D� -b3 �a �--oo Page number
3G
Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or
March 1, cunent year March ent year /�DO� owner? ❑ Yes ❑ No
�3 DC�o
If no, what is his / her exact share of
If name on record is diHerent than that
of mortgagee or wntrect seller
below:
of mortgagee or contract seiler (number and st2et, city,
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street,
Does applicant own property in any
county in Indiana?
Deduc6on approved in the amount of:
20 Q!� I 20 ��
y
state,
If yes, what cow
�/l/��
County Auditor
If owned with someone other than spouse, indicate with whom.
ZIP
Is the property in question:
❑ Real Property ❑ Mobile Home pC 61.1-
7niu �1,�-�. o S_ �i 8`�
Drawer NO ...................
Card NO. . �� .. /./.J.�.�
:tion been requested an
rrent year? � Yes� No
� zo Uo 2o O� zo
P � �
Date
We certify under the penalty of perjury that the above and foregoing infortnation is true and corcect and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
address of applicant �Address of authorized person