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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
S M� ! State Fortn 43709 (R5 / 4-03)
Prescribed by Department ot Local Govemment Finance
Coun Township Year
��UCTIONS: �de Markt
r be �led in person or by mail with the County Auditor of the county whe2 the property is located. �� {; ��
Filing Dafes: 1J Real Property: Dunng the 12 months be(ore May 11 of the year the deduction is to be ech :1.J ��
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year theN O V�tO 5' ZU�� el%ctive.
See reverse side for additional inshuctions and qualiTcations.
Applicant (owner
Taxing
see restrictions on
Key number / legal
Record number � �
� Q �_ Q�� //\ � O O Page number
�V
Assess value of real property as of Mortgage / Canlrect indebtedness unpaid as of Is the applicant the sole legal or equite
March 1, current year March 1, current year Q owner? ❑ Yes ❑ No
�3��
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 lhat of applicant, indicate below: Is the property in question:
` , ❑ Real PropeAy ❑ Mobile Home (IC 61.
Name of mortgagee or contract seller �/�
\�ress of mortgagee or contract seller (number and street city, stafe, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sfreet ciry, state, ZIP code)
Does applicant own property in any other If yes, what county7
county in Indiana?
Deduction approved in the amount of:
20 D� I 20 (/b _ I 20
�
What Taxing District?
COUNTY AUDITOR
20 Q_'/_ � 20
I � I P
Counry Auditor
Has this deduction been requested on
property for current year? ❑ Yes❑ No
20 O � 20
�
)ate
I/ We certify under the penalty of p ury t the above and foregoing infortnation is true and correct and that the applicants was / were
a resident of Indiana and owne he afor mentioned property on March 7, 20
"�n e(owners full me Person aulhorized by duly executed Power of Attomey
, or by IC 6-1.1-12-.07
i •
=u11 resident address of applicant Address of authorized person
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