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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�s ,«. / State Fwm 43709 (R5 / 6-03)
Prescn
� DcE Dy Departrn:r, o� Local Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months belore May 11 01 the year the deduction is to be e/i����nnF
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o/the year f5`th be eHective.
See reverse side for additional instructions and aualifications
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Applicant (owner or contract b e see restrictions on ide) ��) �./(/ // l
Taxing Distrid Key number / le al d�,scrjpti�� � Record num r O�
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curcent year March 1, current year ownef? ❑ Yes ❑ No
If ,io, what is his / her exact
If name on record is different than that of applirant, indicate below:
'ame o( mortgagee or contrect seller
Address of mortgagee or contrad seller (number and street, city.
of assfgnee or other owner or holder of mortgage
Address of assignee (numberand sfresL iity, state. ZlP
owned with someone ather than spouse, indicate with whom.
ZIP
Does applicant own nroperty in any oth�� I �! •-�; v�hat cnunh�' -� 3t Taxing DistriG?
county ir Indiana? � �
– - _ , ��(�?'.�� oR — --
�Y����er � -
Deducfion approved m ihE '
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Signature
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__ .___. ___ County Auditor
Is the property in question:
❑ Real Property ❑ Mobile Home QC Fr1.1-�
Has this deduclion been requested on
property for current year? � Yes � No
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Date
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V�t� rr�tibj under!h� p:�❑alty of per;��r� n:,t P�P above and for�aoino info:ma��un is hu� and corred and that the applicants was /were
recirient o( Indiana and owner o( tha afnrementioned propeRy on March 1. '0 __
��re lnwnr.r's `'��� �p�am.�) q/J person a�a�hnrized by duly executeA Power nf Httomey
- .��--°'—.-/'-�! �7J'_�� _ or by IG 6-1.1-12-.07
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Address of authorized person