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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES�
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709 (RS / 4-03)
Presaibed by Department of Loral Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the CountyAuditor of the county whe2 the property is
Filing Dates: 1J Real Property: During the 12 months before May 11 0/ the year the deduction is to 6e e/%,qti �e.� .� /UU�
2) Mo6ile Homes assessed under IC 6-1.1-7: Befween January 15 and March 2 0/ the year �he de ucholP�s o be eHective.
See reverse side lor additional instructions and qual�cations.
Taxing
Assessed value of real property a4of
March 1, current year
side)
IKey number / legal description I Record number
- 9�- 00�/ �b
Ol�/ _ /'l/r(47 n-� Pagenumber //, i��
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Mortgage / Contract indebtedness unpaid as of Is the applirant the sole legal or equitable
March 1 rrent year O Q, owner? ❑ Yes ❑ No
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If no, what is his / her exact share of interest?
If owned with someone other than spouse, indicate with whom.
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If name on record is different than that of applicant, indicate below:
re of mortgagee or contract selle
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Address o ortgagee or contract seller (number and street, city, state.
Name of assignee or other owner or holder of mortgage
sheet, ciry, state,
Does applicant own property in any other If yes, what county?
county in Indiana?
DeducGon approved in the amount of:
20 Q� � 20
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Signature
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P��vL� t'ors
R osE �� y,�
.�e (IC E1.
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Taxing strict? Has lhis deduction been requested on
propertyforcurtentyear? ❑ Yes❑ No
COUNTY AUDITOR
20
County Auditor
20
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20
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20
We certify under the penalty of perjury that the above and foregoing information is true and corcect and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
full name)
executed Power of Attorney
or by IC 6-1.1-12-.07
7 IAddress of authorized person
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