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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
�FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
State Form 43709 (RS / 4-03) .
PresaiEetl by Department of Local Govemmem Finance
�
INSTRUCTIONS: NOV O �'�PQ{�`i` �
To be filed in person or 6y mail with the County Auditor o/ the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months be(ore May 11 0/ the year the deduction is t effective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0l t year t c is to e ctive.
See reverse side lor additional inst�uctions and qualifications. GI� Y AUDITOR
Applicant
Taxing
Assessed value ofrealproperty
March 1, cunent year
see resttictl on rev�rs side) ♦
I number / legal description
of
no, what is his / her exact share of interest?
Record number
��-a���9 � r
Mortgage / ContraU indebtedness unpaid as of
March 1. current vear
If name on record is different than that of applicant, indicate below:
��me of mortgagee or contract seiler
Address ot mortgagee or contrad seller (number and st�eef, city, s.
Name of assignee or other owner or
Address
l ,� c�, }�,'
�
c �✓'� - �-(/ �
De
20
Signature
O "�f � � � � V
_...: amount of:
Za ��� � I � 20
mortgage
?IP code)
Aunry?
number
�
Is the applicant the sole legal or equitable
owneR ❑ Yes ❑ No
owned with someone other than spouse, indicate with whom.
- �a -if� /QD -
ZIP
What Taxing Distnd?
COUNTY AUDITOR
20 6 20
P
County Auditor
❑ Real
: a7% OG/
❑ Mobile Hane (IC 6-1.1-�
Has this dedudion been requested on
propeAy for wnent year? � Yes ❑ No
20
Dafe
20
We certify under ihe penalty of perjury lhat the above and foregoing information is true and corred and that the applicants was / were
�sic�ient of Indiana and owner of the aforementioned property on March 1, 20
(ull name)
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of applicant � Address of authorized person
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