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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION C u s' Year
S / State Fortn 43709 (RS / 4-03) �
�«•
� PrasuiDed by Department ol Loral Govemmeni Finance
DEC 17
INSTRUCTIONS: Fil - ark
To be filed in person or by mail with the County Auditor of the county whe2 the property is locate .
Filing Dates: 1) Real Pioperty: During the 12 months before May 11 0/ the year the deduction is t
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 oI �tE19�0� �n��iT�e ective.
See reverse side for additional instructions and qualifrcations.
7
Tauing Distrid
�
Assessed value of real property as of
March 1, wrrenl year
no, what is his / her exact share of
on reverse side)
Key number / legal description
Ol �' O�i
MoAgage / Contrad ii
March 1, current year
If name on record is different than that of applicant, indicate
mortgagee or contrad seller
Address of mortgagee or contraIX seller (number and sfreet, city,
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand street, ciry, state, ZIP
Record number Q
_ 'rn Page number �' n
�� a�7
s unpaid as of Is the applicant the sole legal or equitable
owneR ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
ZIP
i
Does applicant own property in any other I If yes, what county? What Taxing District?
county in Indiana?
—�-- -. � �
�� _ • -"NTYAUDITOR
1 �'(/CZ /�_
Deduction ap �
20 � ,(� �y �_ 20
H I u O /'—/�/� �
Signature
County Auditor
Is the property in question:
❑ Real Propeaty p Mobile Home QC 61.1-�
Has this dedudion been requested on
property for current year?� Yes❑ No
zo
Date
�
certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
(ull
resident addPE•ss-ef'a�
9zs s,W,A:..
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Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person