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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (R4 / 10-01)
Prescribe0 by Depanmenl of Local Govemment Finance
Coun Township Year
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INSTRUCTIONS: p Mark
To be filed in person or 6y mail with fhe County Auditor o/ the county where the property is located. � A ry 3� Z�U�
Filing Dates: 1) Real P�opeRy: During the 12 months belore May 11 of the yea� the deduction�is to be el/ective�.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 3j1/ol the year fhe deductioNis to�be effective.
See reverse side (or additional rnstructions and qualifications. '�� �J�����`�l�/ � -�/
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Applicant (owner or contract b r see restnct ons on re rs side)
Taxing Distrid Key number / legal description Record number ��
/C �'J�/��,Q �/6_ �OC��� Pagenumber �
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Assessed value of real pro of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, �ent year owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is lhe property in question:
❑ Real P�operty ❑ Mobile Hane (IC 61.1-�
�ame of morigagee or contrect seller
Address of moRgagee or contrad seller (number and st2et, city, state, ZIP �
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand street, city, state, ZIP code)
Does appliqnt own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for wrrent year? � Yes❑ No
COUNTY AUDITOR
Deduction approved in the amounl of:
20 20 f2� 20 0� 20 �_ 20 �� 20 �� 20 ��
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Signature County Auditor Date
I/ We certify under lhe penalty of peryury lhat the above and foregoing infortnation is true and corred and that the applicants was / were
•!resideni of Indiana and owner of lhe aforementioned property on Marcti 1, 20
i re (owners full name) Person authorized by duly executed Power of Attomey
�'�-a�_�„��.� or by IC 6-1.1-12-.07
� ent address of applicant Address of authorized person
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