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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
� «• / State Fwm 43709 (RS / 4-03)
� PrescriDeO Dy Departmen; ot local Govemmem Finance
To beRU �TION rson or by mail with the County Auditor of the county where the propeRy is loc� �L ��e lvlarfc
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is to be eflective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the ye���ie Qe����s to be eflective.
See reverse side for additional instructions and qualifications.
buyer
Distrid
restrictions on
Key number / legal description Record
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Assessed value of real property as of MoAgage / ConlraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March i, current year March 1, current year �«� �, ' owneR ❑ Yes ❑ No
O(�lV[/V ,�`
If no, what is his / her exact share of interest?
If name on record is difterent Ihan that
of mortgagee or contrad
indicate betow:
If owned wifh someone other than spouse, indicate with whom.
Address of mortgagee or contract selier (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6erand streef, city, state, ZIP code)
Is the property in question:
❑ Real Property p Mobile Home (IC 61.
Does applicant own property in any other If yes. what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for current year?� Yes❑ No
Dedudion approved in the amount of:
20 �
P
Signature
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COUNTY AUDITOR
20 �_ 20 ,
P � �`�
County ud
20
20
Date
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certify under the penalty of perjury that the above and foregoing intormation is true and corred and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
ue (owners full n,!a�me) Person authorized by duly executed Power of Attomey
rn,H fl r. . I 1._„ or by IC 6-1.1-12-.07 •
Address ofauthorized person
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