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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION '
Slate Form 43709 (R4 / 70-01)
PrescribeA by Department of Loral Govemment Finance
Year
INSTRUCTIONS: � � ' F' �1ark
To be filed in person or by mail with the County Auditor o( the county whe2 the property is located. C '.; ��
Filing Dates: 1) Real PropeRy: During the 12 months before May 11 0/ the yea� the deduction is to be��ective. /�/�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 31 of the year the ped�/ion is tnq,4e�;eHective.
See reverse side for additional instrucUons and qualifica6ons. J T,, D��' �
G18S�N C�Ur
Applicant (o er or contract 6uy - see restnctions reverse s' ) .
Taxing Distrid Key n er / legal description Record number a- 8k 7S
/ ' Page number
t �O o� -aCJ - t�d
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrrent year March 1, curtent year ownef? ❑ Yes ❑ No
If no, what is his / her exact share of interesl? If owned with someone other than spouse, indicate with whom.
_ 03- -/�D- l�00. /�/-Oa5`
If name on record is different than lhat of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home pC Crt.t-�
me of moRgagee or contrad seller n
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Address of mortgagee or conVad seller (number and st2et, city tate, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applipnt own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
counfy in Indiana? property for current yeaR� Yes� No
COUNTY AUDITOR
Deduction approved in fhe amount of:
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Signature County Audilor Date
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/ We ceAify under lhe penalty of perjury that the above and foregoing information is frue and corred and that the applicants was / were
resident of Indiana and owner of the aforemenlioned property on MarcFi 1, 20
Si ature (owners lull name) Person authorized by duly executed Power of Atlorney
or by IC 6-1.1-12-.07
u resident ad e s of applicant Address of authorized person
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