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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (RS / 4-03) �
PmscribeE by Department of Local Govemment Finance
Coun Township Year
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INSTRUCTIONS: APR File Mark
To be filed in person or 6y mail with the County Audilor of [he county where the property is located. b 2��4
Filing Dates: 1) Real PropeRy: During fhe 12 months befo2 May 11 01 the year the deduction is to be eflective. �
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is to be/�e8ecb've.
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See reverse side foradditional instructions and qualifications. ' ='SSC�d Ci��r,�7y ;:,.,.,
Taxing Distrid
on r�,G,erse side)
Key number / legal
Record number �
� `% D // � �/�� ,7 -� Page number �O �
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Assessed value of real property as f MoRgage / Contred indebtedness unpaid as of Is the applipnt the sole legal or equitable
March 1, wrrent year March 1, t�ept yearO owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interest?
If name on record is different than that of
of moRgagee or contract selier
indicate below:
If owned with someone other than spouse, indicate with whom.
. �
Is the property in question:
❑ Real PropeAy �❑ Mobile Hane pC Cr1.1-
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Address of mortgagee or contrad seller (number and street, city, state, ZIP �
Drawer NO....
Name of assignee or other owner or holder of mortgage " ••••... „
Ca rd NO. . 0� 1���
Address of assignee (number and street, city, state, ZIP code) � ,
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this deducno�� ...,_.i requested on
county in Indiana? property for current year? � Yes ❑ No
Deduction approved in the amounl of:
20 �_
Signature
20
COUNTY AUDITOR
20 a 9 20 �_ 20 20
,� P e
County Auditor Dat
20
/ We certify under the penalty of perjury that the above and foregoing information is true and correcf and that the applicants was / were
i resident of Indiana and owner of the aforementioned property on March 1, 20
Full resident adrlFess of applicanl"
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Person authorized by duly execu[ed Power of Attomey
or by IC 6-1.1-12-.07
Address of authorized person