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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS ��� �
FOR DEDUCTION FROM ASSESSED VALUATION Coun iTo�yhship ea •
State Fartn 43709 (RS / 4-03) $' � �� � ! �
PrescnGed by Department of Loral Govemment Finance AU r � O� OC
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INSTRUCTIONS: Fde Merk ,��,
To be filed in person or by mail with the County Auditor of the county where the property is located. Q �
Filing Dates: 1) Real Property: During the 12 months 6efore May 11 o/the year the deduction is to be ef/ecti�BSON COUNTY AUDiTOR
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the yea� the deduction is to be effective.
See reverse side for additional instiuctions and qualifications.
appucant
Taxing
orcontract buyer- see restrictions on reverse side)
Assessed value of real property as of
March 1, curtent year
If no, what is his / her exac[ snare of interest?
Key number / legal descri�f ion Record number
�'.lo - id • I 8- /od -�000. i� V�- o�.8
Page number
� � � �
Mortgage / Contract indebtedness unpaid as of Is the applicant
March t, current year $ 3,� a� ownef� I
If name on record is different than that of applicant, indicate below:
of mortgagee or contrad seller
� legal or equitable
❑ No
If dwned with someone other than spouse, indicate with whom.
of mortgagee or conVad selier (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Is the properiy
❑ Mobile Hmie pC St.1-�
Address of assignee (number and st2et, city, sfate, ZIP code) � .
Does applicanl own property in any other If yes, what county? What Taxing District? Has this deduclion been requested on
county in Indiana? propeAy for curtent year?�] Yes❑ No
COUNTYAUDITOR DC��verNO�Y.D�...���
20 _�
r
Signature
approved in the amount o�:
20Q$_ 20 O'
1� P
CardNO . .....................
20 20_ � �i �')�� UU
o�
County Auditor
Date
We certify under the penalty of perjury that the above and foregoing information is true and corred and that lhe applicants was / were
�esident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly exewted Power of Atlomey
or by IC 6-1.1-12-.07
siaent atltlress of applican� ����%,2-`�� Address of aulhorized person
80� � /1'l,�uin ,