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�'�" STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
:: FOR DEDUCTION FROM ASSESSED VALUATION
S J Slate Fortn 43709 (R4l 10-01)
�vu
PrescnDetl Dy Department ot Loal Govemmeni Finance
Coun Township Year
INSTRUCTIONS: MAY F�e�`^�j�Q2
To be filed in person or 6y mail with the County Auditor o/ the county whe2 the property is located.
Filing Dates: 1) Real Property: During the 12 months belore May 11 o/the year the deduction is to be ect�ve.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 31 0/ the ar the ctio to b ffe ive.
See reverse side lor addifional instiuctions and qualifications. CIB�tiT Y AUDI i 0R
a �-i3-i3- � a� ►-r� � �
Applicant (ovmerorcontract
Ta�cing Distrid
- see restnctions on ieverse
legal description � Record number
Page number
— �l �� �'
Assessed value of real property as of Mortgage! Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrzenl year March 1, currenl year ownef? L�les ❑ No
no, what is his / her exad share of interest?
If name on record is di1
�e of mortgagee or
that of appiicant, indicate below:
seller
If owned with someone other lhan spouse, indicale with whom.
of mortgagee or wntrad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sbeet, city, state, ZIP code)
Does applipnt own property in any olher If yes, what county?
county in fndiana?
Dedudion approved in the amount of:
20 FJ 7 � 20 � � 20
�
What Taxing Distrid7
COUNTY AUDITOR
20 �
County Auditor
20 O %
Is the property in queslion:
❑ Mobiie Home (IC 61.
Has lhis deduction been requested on
property for wrcent yea(? 0 Yes ❑ No
20 �b 20 �
1 1
Dale
certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was /
lent of Indiana and owner of the aforemenlioned property on March 1, 20
(owners (ull
iaddress otapp
/ i3�x ba
or by IC 6-1.1-12-.07
of authorized person