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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�+ w� / State Fwm 43709 (RS / 4-03)
� PrescriDeC by DepartmeM of Loral Govemment Finance . .
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located. r � C� 2��4
Filing Dates: 1) Real Property: During the 12 montbs before May 11 of the year the deduction is to be eff�Ctive.�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of/l/he year the deduction is to be �eHective.
See reverse side for additional instructions and qualifications. 1-. .�! .�j+ � /,
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GIF350:I CCUft- ,�(,.; rp^
or contract buyer -�ee 2strictic(r�i on reverse
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Disirict
Key number /
R/�f�rd numbe�O _ � �
\�
Page number
Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the s le legal or
March 1, currenl year March 1, current year owner? �❑ No
y�J�n�
If no, what is his / her exact share of
If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicanl, indicate below:
�me of mortgagee or co/n.tragd seller
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Address of mortgagee or contraG seller (number and st2 , city, state, ZIP
Name of assignee or other owner or holder of mortgage.
Address of assignee (number and street, city, state, ZIP code)
Does appticant own property in any other If yes, what county?
county in Indiana?
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iction approved in the amount of:
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What Ta
Is the
❑ Mobile Hmie (IC 61.1
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COUNTY AUDITOR �
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County Auditor
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Date
20
�s[ea on
'es� No
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We certiy under the penalty of perjury thal the above and foregoing information is true and corred and thal the applicants was / were
resident of Indiana and owner of the aforementioned properiy on March 1, 20
�nature (owners full name) , Person authorized by duly executed Power of Attomey
� �. ���. or by IC 6-1.1-12-.07
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resident �c7dress of applicant '' �Address of authorized person