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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDN
FOR DEDUCTION FROM ASSESSED VALUATION �
State Fortn 43709 (R4 / 70-01) O
PrescnbeO by Department W Local Govemment Finance �1-i�
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Coun Township Year
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor ol the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months before May 11 ot the year fhe deduction is to be e(/ective.
2) Mobile Homes assessed under IC 6-1.1-7: Befween January 15 and March 31 0/ the year the deduction is to be eHective.
See reverse side for additronal instructions and qualifica6ons.
Applicant (ovmer or contract buyer- see resMctio s on reverse side)
Taxing Distrid Key number / legal de ription Record number
Qo � D /D� � "� Page number �
Assesse value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year / owneR ❑ Yes ❑ No
Q. ��,S�a
If no, what is his / her exact share of interest? If owned with sameone other lhan spouse, indicate with whom.
-�� �o -� oo - po . 6 3=G0/
If name on record is different than that of applicant, indicate below: Is the property in queslion:
- ❑ Real PropeAy ❑ Mobile Home (IC Cr1.1-�
"�ame of mortgagee or contrad seller
Address of mortgagee or conVad selier (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this dedudion been requested on
county in Indiana? property for wrrent year?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 � 20 n l� 20 20 20 � 20 �_ 20
�a� � � P
Signature �� County Aud'Aor Date
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I/ We ceAify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
� resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners (ull name) Person authorized by duty executed Power of Attomey
or by IC 6-1.1-12-.07
Full re/sident address of ap nt Address of authorized person
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