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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNES�
FOR DEDUCTION FROM ASSESSED VALUATION
/ State Fwm 43709 (RS / d-03) �
� P'euriDeE hy Departmeni of Local Govemment Financa
INSTRUCTIONS: �
To be filed in person or by mail wdh the Counry Auditor ot the county where the propeRy is
Filing Dates: 1) Real Property: Dunng the 12 months 6efore May 11 0l the year the deduction is to b�e�c�v� 7nn�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 01 the a h dGdbBlftlh is to be ef/ective.
See reverse side for additional instructions and qualificaiions. �Q� ��
Applicant
Taxing
Assessed value of rE#
March 1, wrrent year
see resr�nons on reverse
Key numbef�legal
Record number
�� /_ � _ � � � Page number �
��
d — �lLIJ Od .S�l
as of Mortgage / ContraU indebtedness unpaid as of is ihe applicant the sole legal or
March 1, current year ownef? ❑ Yes ❑ No
� � rl _ r .an-r� -,
If no, what is his / her exact share
If name on record is different lhan that of applicanl,
mortgagee or contract seiler
Address of mortgagee or conlraq seller
If owned with someone other than spouse, indicate with whom.
below: .
street, cit}�state, ZIP
Name of assignee or other owner or holder of mortgage
(numberand st2et, city, state, ZIP
Does applicant own property in any other If yes, what county? What Taxing Distrid?
wunty in fndiana? .
COUNTY AUDITOR
Deduc6on approved in the amounl of:
20 6 7 20 �i 20 �
� P P
Signature _ _ __
20
County Auditor
�
Is the property in question:
� Real Property ❑ Mobile Horr�e (IC 61.1
Has this dedudion been requested on
property for wrrent yeaR � Yes� No
20
20
iWe certiry under the penalty of perjury that the above and foregoing infortnation is true and corred and thal the applicants was / were
resid t of Indiana and owner of the aforementioned property on March 1, 20
n ure ( ners (WI name) Person authorized by duty executed Power of Attomey
or by IC 6-1.1-12-.07
ill resi ent a ress appli nt A ress of authorized person
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