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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Stale Fwm 43709 (R6l 5-OG)
Presaibed by Deparimenl of Loral Gwemment Finance
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INSTRUCTIONS: DEL 2 yICUU�
To be filed in pe�son or by mail with the County Audito� of the county where the property is located.
Filing Dates: i) Real PropeRy: During the 12 months before June � 1 0/ the year lhe deduction is to be eliective.
2J Mobile Homes assessed under IC 6-1 J-7: Behveen January 15 and March 2 0/ the year�tlt�deduCBoj�js,to be elfective.
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See reverse side for additional inslructions and qualifications. ��P 5,�,,, �p��TY F.� 1TOR
Appiicant (ownerorcontra b yer- sMdions on v rse side)
Taxing Distrid n mb r/ legal desuiption Record number C p
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(� d e 3-�b 3S9 -oa Page number 7 S 3 S�
Assessed value of real properiy as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curcent year March 1, current year ownef? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone olher than spouse, indicate wilh whom.
If name on record is different lhan that of applicanl, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-�
me of mortgagee or contrad seller
Address of moRgagee or contrad seller (nu ber and street, city, state, ZIP
Name of assignee or other owner ar holder of mortgage
Address of assignee (num6er and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this deduqion been requested on
county in Indiana? property for current year? �] Yes ❑ No
COUNTY AUDITOR
Dedudion approved in the amounl of:
20 0 20 �� 20 � 20 20 20 20
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Signature County Auditor Date
�/ We certify under the penalty of perjury lhal lhe above and foregoing information is true and corred and thal the applicants was / were
� a resident of Indiana and owner of the aforementione property on March 1, 20
Signature (o nef 11 name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Ful resid nt addre of a li Address of authorized person
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