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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Stare Fwm 43709 (RS / 4-03) � . . • � � . . �
PresaiGed Dy Department of Loral Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor o( the county whe�e the property is located. y
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is to be�ehecti e. ZOO¢
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and Maich 2 o7�the year the deduction is to 6e ef/ective.
See reverse side for additional instructions and qualifications. � /j n
i; _ _.�-�I�c.f/
or contract
Assessed value of re:
March 1, wrrent year
see restrictions on reverse
_ . I Key number / legal
� 1 �o � C..�
as of MoAgage / ContreU i�
March 1, wrrent yeer
If no, what is his / her exact share of interest?
If name on record is different lhan that of applicant, in
;ame of mortgagee or contrad seller �
I•
Address of mortgagee or contract seller (number and
Name of assignee or other owner or holder of mortgage
below:
of assignee (number and street, city, slate, ZIP code)
Record number
Page number
unpaid as of Is the applicant the sole legal or equitable
owne(? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
state.
Does applicant own property in any other I It y�s, �.ahat couMy? �!Nhat Taxing Disirict?
county in Indiana? I
Deduction approved in the amount of:
20��
Signature
20 J �' � 20 �Z
COUN�' AUDITOR
�IL'<Zi7
P I P
County Auditor
Is the property in question:
❑ Real Property O Modle Home pC 61.
Has this deduction been requested on
property for current yeaf.� n Yes ❑ No
20
Date
20
We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
'esidenl of Indiana and owner of the aorementioned property on March 1, 20
(owners full name) �
.�- . , _
Person authorized by duly execuled Power of Attomey
or by IC 6-1J-12-.07