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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
• FOR DEDUCTION FROM ASSESSED VALUATION
S�M ! Sfate Fwm 43709 (RS / 4-03)
Prescribed by Department of Local Govemment Finance
�RUCTIONS: � � �, Ei�M�
To be filed in person or 6y mail with the County Auditor of the county whe�e the property is /ocat �"�
Filing Dates: 1) Real Property: During the 12 months before May 110l the year the deduction is to be �ive. -�nQ�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0l the yea dedt% Yi i to be eNective.
See reverse side for additronal instructions and qualifications. /
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Applicant o er o� contract 6uyer- see res ns on reverse side) °"""'.. "`-
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Taxing Di trict Key number / legal description Record number Q
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Assessed value of r al roperty as of Mortgage / Contracl indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent yea March 1, current year owner? ❑ Yes ❑ No
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1f no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
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If name on record is different than that of applicant, indicate below: �3 Is the roperty in question:
Q � ❑ Real Property ❑ Mobile Home QC 61.1•7)
Name of mortgagee or wntrect seller
�iress of mortgagee or contract seller (number and street, city, state. ZIP
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Name of assignee or other owner or holder of mortgage
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Address of assignee (number and street, ciry, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Dislrict? Has this deduction 6een requesied on
counry in Indiana? property for current year? ❑ Yes � No
COUNTY AUDITOR
Deduction approved in the amouni of:
20 o zo �,� zo 20 �7 zo 09 20 �`L zo
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Signature County Auditor Date
I/ We certify under the penalty of perjury that the above and foregoing infortnation is true and correct and that the applicants was / were
a resident of Indiana and owner oi the aforementioned property on March 1, 20
-�n �(owners full name Person authorized by duly executed Power of Attomey
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'ull resident add s of applicant , Q� /� _ Address of authorized person
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