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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�'. � / State Form 43709 (RS / 4-03) .
� P25cnbetl by Department of Local Govemment Finance
INSTRUCTIONS:
To 6e filed in person or by mail with the County Auditor o/ the county where the propeRy is IocaL _.
Filing Dates: 1J Real Property: During the 12 months be%re May 11 0/ fhe year the deduciion is to be e�qye� C,n�
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year tri'e`�d ui�tieN o be eNective.
See reverse side lor additional instiuctions and qualiTcations. �
buyer-
Assessed value oi real property as of
March 1, current year
side)
Key number / �egal description Record number �
Q�'Q � /jOOQ1N_�^1 Pagenumber � �
�/ U 0 ���
MoAgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year ownef? ❑ Yes ❑ No
If no; what is his / her exact share of interest? �--
If name on record is different lhan that of applicant, indicate below:
of mortgagee or conlrad seller
Address of mortgagee or contraIX seller (number and
Name of assignee or other owner or holder of mortgage
of assignee (number and street,
Does applicant own property in any
county in Indiana?
state, ZlPCOde)
I( yes, what county?
1 .
If owned with someone
ZIP
What Taxing District?
COUNTY AUDITOR
)edudion approved in the amount of:
20� 20 20 0� PO 20
1 � \ I I�
iignature County Auditor
than spouse,�indicate with whom.
V -`�+�•V U 'VV J
Is the property in question:
❑ Real Property ❑ Mobile Hane (IC 61.1-�
�� �9�J�'
Has this dedudion been requested on
property for wnenf year?� Yes� No
20
Date
20
ffy under the penalty of peryury that the above and foregoing information is true and corred and thal the applicanls was / were
of Indiana and owner of the aforementioned property on March 1, 20
�wners (ull name) Person authorized by duly executed Power of Attorney
or by IC 6-t.t-12-.07
authorized person