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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION
1 i�«� ! State Fwm 43709 (R5 I 4-03)
� Prescn�ed by Department of Loral Govemment Finance
INSTRUCTIONS:
Coun Township Year
File Mark
To be filed in person or by mail with the County Auditor o! the county where the property is located. SE P� 2 2003
Filing Dates: 1) Real Property: Dunng the 12 months 6efore May 11 0) the year the deduction is tq-be effective.
2) Mo6ile Homes assessed under IC 6-1.1J: Between January 15 and Maich 2 of tff year tf e d u' n �s to e ctive.
See 2verse side for additional insfructions and qualifications. GIB� T`! FUDITOR
Applicant (owner or contract buyer- see restrictions on reverse si e)
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Taxing Distrid Key number / legal escription Record number
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- Page number
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant�ole legal or equitable
March 1, current year March 1, current year owne(? s❑ No
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If no, what is his / her exact share of interesl? If owned with someone olher than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
eal Property ❑ Modle Horne (IC 61.1-�
'�me of mortgagee or contrad seller
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Addr ss of mortgagee or contraq seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code) "-- —--
Does appiicant own propeRy in any other If yes, what wunry? Drawer 1V0„Q� 4 been requested on
county in Indiana? ��� �'�+' : yeaR� Yes❑ No
Card NO. ........
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Deduction approved in the amount of:
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Signature County Auditor Date
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�'/ We certify under the penalty of perjury that the above and foregoing information is lrue and corred and that the applicants was 1 were
resident of Indiana and owner of the atorementioned property on March 1, 20
Signafure (owners (ulf name) Person authorized by duly executed Power of Attorney
����=Q or by IC 6-1.1-12-.07
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F resident address of applicant Address of authorized person
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