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R'" STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
-' � FOR DEDUCTION FROM ASSESSED VALUATION
�, � � Slate Form 43709 (R4/ 10-01) � - �
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: PrescribeA by Department ot Local Govemmeni Finance
INSTRUCTIONS:
Coun Township Year
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To be filed in person or by mail with lhe County Auditor o/ the county where the propeRy is located. �. � � ��
Filing Dates: 1) Real Praperty: During the 12 monfhs belore May 11 0/ the year the deduction is to 6e e(/ective.
2) Mobile Homes assessed under IC 6-1.1-7: Behveen January 15 and Ma�ch 31 0/ th�year.the-deduc6on-ts'to-be'eNective.
See reverse side /or addifional instructions and quali�cafions.
�' GI3SON Ci�U�T`.' AUDITOR 1
Applicant (owne� or contracf buyer - see restrictions on reverse side)
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Taxing Distrid Key number / Iegai descriptio Record number
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applica�jt �th,e, sole legal or equitable
March t, curtent year March t, current year owneR `�'es ❑ No
1
I( no, what is his / her exad share of interesl? If owned with seSneone other than spouse, indicate with whom.
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If name on record is different than lhat ot appficant, indicate below: Is the property in queslion:
eal Property ❑ Mobile Hortie (IC 61.1-�
^�ame of moAgagee or conVad selier
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Address of mortgagee or contract seller (number and sfreet, city, s fe, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6erand street, city, state, ZIP code)
Dces applipnt own property in any other If yes, what wunty? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for curtent yeaR � Yes � No
COUNTY AUDITOR
Deduction approved in the amounl of:
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Signature ,� . County Audftor Date
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I./ We certify under the p nalry of perjury that the above and foregoing infortnation is true and correct and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signa (owners full na Person aulhorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
F I re,' nt addr of app icant Address of authorizeil person
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