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f�� 4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
r' = FOR DEDUCTION FROM ASSESSED VALUATION � Count Township Year
4_w ! State Form 43709 (R6 / 5-06) ^ �
�� Presaibed by Department of Loral Gwemment Finance �\
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INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Audilor ot the counfy where the property is located.
Filing Dates: 1) Real P�opeRy: Dunng the 12 monfhs before June 11 of the year the deduction is to be elfective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deducUon is to be effective.
See reverse side fo� additional instructions and qual�cations. ��5 '1 �P ���
Applicant (o er contract buy - see iestri ' n ieverse side)
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Taxing Distnd y number / legal description Record number
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p / Page number
p —�d(o �
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applipnt the sole legal or equitable
March 1, wrrent year March 1, cunent year owneR ❑ Yes ❑ No
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 difierent than that of applicant, indicate below: Is the property in question:
❑ Reai Properiy ❑ Mobile Home (IC 61.1-�
e of mortgagee or contrad seller
Address of moRgagee or conVact seller (num and street, p, sta e, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Dces appliwnt own properiy in any other If yes, what counry? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for curtent yeaR � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amounf of:
20 20 20 20 20 20 20
1
Signature County Auditor Date
e certify under the penalty of perjury lhat the above and foregoing infortnation is true and corred and that the applicanls was / were
sident of Indiana and awner of the aforementioned property on March 1, 20
Signature (owners (ull name) Person authorized by duly executed Power of Attomey
��� � ��y� or by IC 6-1.1-12-.07
Full res' ent address of applicant Address of authorized person
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