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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
's N� J State Fortn 43709 (RS / 4-03) - ,
� ResaiEed Cy Departmeni of Local Govemment Finance � �
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor o/ the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months 6elore May 11 0/ fhe year the deduction is to be et(��e6 — ZOO�
. 2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year tAe deduction is o be effective.
See reverse side for additional instructions and qualifications. `�jj_ ��
Applicant (owner or contract bu r- ee restrictions on revers side
Taxina Dict�n _ �ber /�al escription Record number ��
J'� � _ . _ .._ Page number
.3 -DOa. o/� O � �
Assessed value of real properly as of Mortgage / Contract indebtedness unpaid as of Is the applicant the so e legal or equitable
March 1, wrrent year March 1, current year owner? ❑ Yes ❑ No
as�o,�: ,��
Ii no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on rewrd is different than that
of mortgagee or contrad
indicate below:
Address of mortgagee or conlrect seller (number and street, city, state, �
assignee or other ownf
Address of assignee (numberai
Does appiicant own properfy in e
county in Indiana?
approved in the amou
❑ Real
-:. ,
f Ci n 1 _
20 �� 20 �a_
Q T
Signature
certify under the penaRy c
lent of Indiana and owner
0
�
�� .
�
❑ Mobile Home QC 6-1.1-�
deduclion been requested on
for current yeaR � Yes 0 No
20
7 that lhe applicants was 1 were
� c„v�� c�u��i�cou uy uuiy ate�u�ed Power o(Attomey
or by IC 6-1.1-12-.07
Address ofauthorized person