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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (RS / 4-03) ,
PrestriDed �y Department of Local Govemment Finance
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INSTRUCTIONS: . File Mark
To be Fled in person or by mail with the County Auditor of the county where the property is located. N O V V q l��§
Filing Dates: 1) Real PropeRy: During the 12 months before May 11 0/ the year the deduction is to be eflective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0! the year t deduction t� efle ' e.
See reverse side lor additional instructions and qualifications. ��B/� TY nUDITOR
Applicant (owner or �tract yer - se tnctions on ieverse side
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Taxing Disiricl Key number / legal description Record numberO �/
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is lhe applicant —th/e sole legal or equitable
March 1, cunent year March 1, current year ownef? �Yes ❑ No
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If no, what is his / her exact share of interest? Ii owned with someone other than spouse, indicate with whom.
If name on record is diHerent than lhat of applicant, indicate below: Is the operty in question:
eal Property ❑ Mobile Home QC 6-1.1-�
�me of mortgagee or contract seller
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Address of mortgagee or contract sel er umber and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does appticant own property in any other If yes, what counry? What Taxing District? Has this dedudion been requested on
counfy in Indiana? property for current year?� Yes❑ No
� � 5 COUNTY AUDITOR
Deduction approved in the amount of:
20 � 20 6 Z 20 �� 20 Q9 _ 20 20 20
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Signature County Auditor Date
We certiy un r the penalty of perjury that the above and foregoing intormation is true and corred and ihat the applicants was / were
:sident of a a and own of he afo mentioned property on March 1, 20
S' ature � ne full e) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full r ident address f appliqn Address of authorized person
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