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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES�
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R6 / 5-06)
Presaibed by Department of Lopl Gwemment Finance
INSTRUCTIONS:
To 6e (iled in person o� by mail with the CountyAudifor of the county where the propeRy is
Filing Dates: 7) Real Property: Dunng fhe 12 months be%ra June 11 o/the year the deduction is to be g�q��tixe.� �007.
2) Mobile Homes assessed under IC 6-7.7-7: Between January 15 and March 2 0/ the ye�'itle ile u �on �s lo be eRective.
See reverse side fo� additional instructions and qualifrcations.
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Applicant (ownerorcont yner- 'se'e rest ' ons on reve side) —� -- -- �
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Taxing District Key number / legal descri n / Record number ^�
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`� O oO Pagenumber
C _ �.o-, _ �oo -oDO. �8-0o a� :
Assessed value of real property as of MoAgage / Contred indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, currenl year 5� / �,� q 3� owne(? ❑ Yes ❑ No
S000
If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
name on record is
of mortgagee or contract seller
Address of mortgagee or contrad seller (number and street, city, state, ZIP
of assignee or other owner or holder of mortgage
assignee (num6erand street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid?
county in Indiana?
Deduction apprc
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GE.oRC�s, CA d�o,4 S
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COUNTY AUDITOR
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Is the property
■• ••S_y ■ ..-
61.
Has this dedudion been requested on
property for wrrent yea(? � Yes ❑ No
20
Date
20
'/ We certify under the penalty of peryury ihat the above and foregoing information is true and corred and lhat the applicants was / were
a resident of indiana and owner of lhe aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Address oi authorized person