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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
S , State Fwm 43709 (RS / 4-03)
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� PfasaiGed by Depanment of Local Govemment Finance
INSTRUCTIONS:
Coun Township Year
�� ��'� �
MAR ¢;� �4
To 6e filed in person or by mail with the County Auditor o) the county whe2 the property is located. �` �j
Filing Dates: 1J Real Property: During the 12 months before May 11 o/the year the deduction is fo be eBective.� `J� /J
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of !he yeai fheiieduction is to-bi�'�ve.
'�g��_,." `-"�'^�'v ,ilD1TCS: -
See reverse side for additional instn�ctions and qualifications.
Applica (owne�orcontract u�r-�st ctionson vers
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Taxing ' rict Ke umber / legal description Record numberrl L j
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j � /�_ NI//�_ D� Page number
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Assessed value of real property as Mortgage / Contrad indebtedness unpaid as of Is the applicant the s e egal or equitable
March 1, current year March 1, current year owneR es ❑ No
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If no, what is his / her exact share ot interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is�lhe �property in question:
L/�Keal Property ❑ Mobile Home pC 61.1-�
�me of mortgagee or contract seller �
Address of mortgagee or contrect seiler (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and st2et, city, sfate, ZIP code)
Does applicant own property in any olher If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for current year? � Yes❑ No
� � � t � � COUNTY AUDITOR
Deduction approved in the amounl of:
20 �_ 20 20 (i 7 20 � 20 � 20 20
D� P P
Signalure County Auditor Dale
/ We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Sig ature (owners full name) Person authorized by duly executed Power of Attorney
��(�� or by IC 6-1.1-12-.07
F II resident addre of applicant Address of authorized person