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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709 (R4 / t0-Ot)
PrescribeA Dy Deparimenl o( Local Govemmeni Finance
INSTRUCTIONS: � �- "'j y File Mark
To 6e filed in person or by mail with the County Auditor of the county whe2 the property is located. I U'L��3
Filing Dates: 1) Real PropeRy: During the 12 months belore May 11 0! the year the deduction is to 6�$f�ecfve.
2) Mo6ile Homes assessed �nder IC 6-1.1-7: Between January 15 and March 31 of the year fhe deduction is" to effective.
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See reverse side Ior additional instructions and ualifications. � `""`"�'
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Appiicant ( e or contract 6uye�ee res 'ons on verse side)
Taxing Dis rid Key number / legal descriplion Record number O
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, current year owneR ❑ Yes ❑ No
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If no, whal 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 the property in question:
❑ Real Property O Mobile Home (IC 61.1-�
�me of mortgagee or contract seller �
Address of mortgagee or contracl seller (number and street, Gty, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP code)
Does applicant own property in any other If yes, what wunty? What Taxing Distrid? Has lhis dedudion been requested on
county in Indiana? property for current year? � Yes 0 No
COUNTY AUDITOR _
Deduction approved in the amount of:
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Signature County Audftor Date
�/ We certiy under the penalty of perjury that the above and foregoing infortnation is true and corred and that lhe applicants was / were
�. resident of Indiana and owner of the aforemenlioned property on March 1, 20
Sign ture (owners full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Fu eside address applipnt Address of authorized person
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