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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES�
FOR DEDUCTION FROM ASSESSED VALUATION
Sfare Fwm 43709 (RS / 4-03)
Prescribeq by Departrr�nl o( Locai Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county wheie [he property is
Filing Dates: 1) Real Property: During the 12 months be%re May 11 0/ the year the deduction is to 6e efle�� 1 5 2��5
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year fhe deduction is to be ehective.
See reverse side for additional instructions and qualifications. �,�+�,
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_�.,�nu r.OUNTY AUD�TOR
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Taxing
Assessed value of real �perty as of
March 1, current year
�io, what is his / her exact share of
Key number / legal descrip[ion Record number D[
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MoRgage / Contred indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, current year ownef? ❑ Yes ❑ No
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If owned with someone other lhan spouse, indicate with whom.
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If name on record is diHerent than that of applicant, indicate bek,w:
moAgagee or contrad seller
Address of mortgagee or contract seller (number and s12et, city. state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street: city, state. ZfP code)
Does applirant own propeRy in any oth�r I N•�:�; 4^hat cnunty? �Vhat Tauing Distrid?
county ir Indiana? I
COUNTY AUDI70R
DeduCtion appro�:ed in fhe am�nvt nf:
20 �f --I 2�_0_¢ ' �� 4�
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Signalure
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County Auditor
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❑ Real Property ❑ Mobile Home (IC G1.1-�
Has this dedudion been requested on
property for current yeaR � Yes ❑ No
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Date
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ce�tiPj under Ihn p.�nalty of perjur� rha� tha above and forcaoino info:matfon is �ru� and corred and that ihe applicants was / were
�pnt of Indiana ?nd owner of thP aforementioned property on March t 20 __
i ture lownerc `d� r•ame) J
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Full sident aridress of aoolicanl
Person aWhnrized by duly executeA Power of Nttorney
or by IG 6-1.1-12-.07
of authonzed person