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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
= FOR DEDUCTION FROM ASSESSED VALUATION Co 7ow hi Year
�a N� / Sute Form 43709 (RS / 4-03) ' ,
� Prescn�ed by Depanment of Loral Govemmant Finance
A R nc
INSTRUCTIONS: � Fµ ��
To be filed in person or by mail with the Counry Auditor of fhe county whe2 the property is located a a.
Filing Dates: 1) Real Property: During the 12 months before May 11 o/the year fhe deduction is to be �'l6&4Yd.00UNTY AUDITOR
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of tAe year the deduction is to be effective.
See reverse side for additional instructions and qualifications.
Applicant (owner or contrac!`�t`6uyer - see
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Taxing Dislrid
�'���m. ,ti � ,
Assessed value of real properly f
March 1, current year
on reverse side)
Key number / legal description
MoAg�age / ConlrOaG i
March 1, current year
If no, what is his / her exact share of interest?
If name ori record is different lhan ihal of applicant, indicate
of mortgagee or conlrad seller
Address of mortgagee�o} cantrect seller
of assignee or other owner or
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Page number �—
bndebtedness unpsaid as of Is lhe applican the�sole gal or equitable
. owne(? �es ❑ No
I
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If owned with someone other thari spouse, indicate with whom.
�� Is the orooertv in auestion:
and street, city, state, ZIP
mortgage
of assignee (number and stieet, city, state, ZIP code)
Does applicant own property in any
county in Indiana?
approved in the amount of: -
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t
Signalure�_
❑ Mobile Home QC 61.1-�
S
Drawer NO..°?�...:a?� /•
It yes, what county? Card ti0 . .....................
i requested on
_ _... � �a�? (] Yes � No
COUNTY AUDITOR
20 _�]_ 20 20
Q
County Auditor
20
Date
FZ�7
,We certify under the penalty of perjury that the above and foregoing information is true and corred and thal the applicants was / were
esident of Indiana and owner of the aforeme tioned property on March 1, 20
Signature wners /ull name) Person auihorized by duty executed Power of Attorney
� or by IC 6-1.1-12-.07
F I resident address of applicant Address of authorized person