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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
��� � J State Form 43709 (R5 / 4-03)
� Prescribed by Depertmeni of Local Govemment Finance
Coun Township Year
TRUCTIONS: �Mark
o be filed in person or 6y mail with the County Auditor of [he county where the propeRy.i�locaTed�
Filing Dates: 1) Real Property: Dunng the 12 months befwe May 11 01 the year the dedu� is�to e eBeeBve
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Marcj�2 o(1be ar the deduction is fo be effective.
See reverse side for additional inshuctions and qualifications. O CT 3 U 2��3
Applicant (owner or c<
Taxing District
�
Assessed value of re�
March 1, current year
�er - see restrictions verse side)
Key number / legal de
l —�
as of Mortgage / Contract ir
March 1. current vear
no, what is his / her exact share of interest?
If name on record is different than that of applicant, indicate below:
Name of mortgagee or contract seller
ot mortgagee or contract seller (number and
Name of assignee or other owner or holder of mortgage
,
Address of assignee (num6er and streef, city, state, ZIP code)
Does appficant own property in any other I If yes, what countyl
county in Indiana?
Deduction approved in the amount of:
20
Signature
20 n t�
S - �t5
edness unpaid as o'
�, o�v
•r
Page number
�
Is the applicant the sole legal
owner? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
ZIP
What Taxing District?
❑ Real
❑ Mobile Hane (IC 61.
Has this deduction been requested on
property for curtent year? ❑ Yes ❑ No
COUNTY AUDITOR
20 � 20 � 20 _Q� 20 � 20
P P
Counry Auditor Date
I 1/ We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
�� ' a resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power ot Attomey
or by IC 6-1.1-12-.07
Address of authorized person