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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION u' � 7"owns . Year
�' J Siate Form 43709 (R5/ a-03) a_,/ �
� M PreSCnDed Dy Departmeni ol Loral Govemment Finance
INSTRUCTIONS: `-�-n� ��e Maric
To 6e filed in person or by mail with the County Auditor o/ the county where the property is located. a�
Filing Dates: 1) Real Property: Dunng the 12 months belore May 11 0/ the year the deduction l3I��CbUBY AUDITOR
2J Mobile Homes assessed under IC 6-1J-7: Between January 15 and March 2 0/ the year fhe deduction is to be effective.
See reverse side for additional insfructions and quali�cations.
6uyer-see
Taxing Distrid
�v"� v � �'
Assessed value of real property as of
March 1, current year
no, what is his / her exact share of
on
Key number /
Record number �
�p _ O� �J �(J ? Page number��/ �^
d� b J ��`J
Mortgage / ContraU indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year /� ��Od ownef? ❑ Yes ❑ No
name on record is diRerent ffian that oi applicant,
o! mortgagee �or contract seller
If owned with someone other than spouse, indicate with whom.
Address of mortgagee or contract sefler (number and �}eet, city, state,
PJame of
or ocner owner or noiaer ot mongage
Haaress or assignee �numoer and st2et, ary, sfafe, LIP code)
'/Of �UCo — U/ �(JU�i..�ri.1—QOi�
Is the property in question:
❑ Real Property ❑ Mobile Hane (IC 61.1-�
Does applipnt own property in any other If yes, what county? What Taxing Districl?
county in Indiana?
Deduction approved in the amount of:
�
Signature
� � _
COUNTY AUDITOR
20 �� 20 20
P
County Auditor
m,� ��'Ah�
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5�4�2�
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RE6� O�� 5 S��ed on
., ,.,� wrrent year? � Yes ❑ No
20
Date
20
' We certify under the penatty of perjury that the above and foregoing intormation is true and corred and that the applicants was! were
resident of Indiana and owner of the aforementioned property on March t, 20
(owners full name)
'// P
Person authorized by duly executed Power of Aftomey
or by IC 6-1.1-12-.07
of authorized person