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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR OEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
�• ! State Fwm 43709 (RS / 4-03) �
,«
� PrescnDed by Department of Local Govemmeni Finance
INSTRUCTIONS: � � �File Mark .
To 6e �led in person or by mail with the CountyAuditor o) the county whe2 the propeRy�is•loca�ed.i� � j� 1
Filing Dates: 1J Real Property: Durrng [he 12 months be/ore May 11 of the year the deduction islto. e.effec '
2) Mobile Homes assessed under lC 6-1.1-7: Between January 15 and Ma�ch 2 oAt��hRy! r��th��duction is to 6e eflective.
See reverse side /or additional instnictions and qualfications. 4
Applicant
see
s on rev r tle
� • .
number / legal description
Record
number
,'I
� i � v
Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is lhe app ica e le al or equitabte
March 1, current year March 1, cunenl year ownef? es ❑ No
,5 OO O
If no, what is his / her exact share of inlerest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the operty in question:
�Pmperty O Mobile Home pC 61.1-7j
of mortgagee or contrad seller ,�
Ac' �^� moAgagee or contract seller (number arn
���-Qo _��
p �� ' --^r.mortg��
'`"-.�S`' �s "'t7b
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counfy in Ina�o,._�
Deduction�pproved in the amounf bf:
20 � 20 � 20
�
Signature
state, ZIP
0
' S'
� O
�t county? Whal Taxing Distrid? Has lhis deduclion been requested on
property for current year? � Yes ❑ No
20 � 20 � 20
� �
County Auditor
Date
�
/ We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
� residenl of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.7-72-.07
address of �plicant , IAddress of authorized person