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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
` FOR DEDUCTION FROM ASSESSED VALUATION �
b�`- / Siate Fwm 43709 (R514-03) b(�
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� Prescn�ed by Department ot Local Govemment Finance a
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INSTRUCTIONS: � \
Coun Township Year
File Mark
To be filed in person or by mail with the Counry Auditor o/ the county where the property is located.
Filing Dates: 1) Real Property: During the 12 mon[hs be/ore May 11 oI fhe year the deduction is fo be eflective.
2) Mobile Homes assessed under IC 6-1.1-7: Be(ween January 15 and March 2 0/ the year fhe deduction is to be eNective.
See reverse side for additional instructions and qualifications.
Appticant (owner or confract buyer- see t' tions n revers ide) e
Taxi�strid Key number / legal description — Record number ��
� I q- o a 5 Page number �
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, currenl year owne(? ❑ Yes ❑ No �,
If no, what is his / her exact share of interest? If owned with someone olher than spouse, indicate with whom.
If name on record is different than fhat of applicanl, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Hort�e pC 61.1-n
�me of mortgagee or contract seller •
Address of mortgagee or contrad seller (number and sfreet, city, state, ZIP
Name of assignee or other owner ar holder of mortgage
Address of assignee (numberand street, city, sfate, ZIP code)
Does applicant own �ounty? What Taxing District? Has this deduclion been requested on ;
county in Indiana? � i )� _DQ_ property for current year? � Yes ❑ Noa�
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COUNTY AUDITOR
DeducGon approved ��— 90 9�
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Signature County Auditor Date
�/ We certify under the penalty of perjury lhat the above and foregoing information is true and corred and that the appiicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
� Signature (owners (ull name) Person authorized by duly exewted Power of Attomey
.� or by IC 6-1.1-12-.07
Full resident address of applicant Address of authorized person
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