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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
��w� i Stata Fwm 43709 (RS / 4-03)
� PiescnpeC Dy Department of Laal Govemment Finance
Coun Township Year
.
INSTRUCTIONS: �(
To be filed in person or by mail with ihe County Auditor ol the county where the property is locate� ���a�
Filing Dates: 1) Real Property: During the 12 months 6efore May 11 0l the year the deduction is t e e ct�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction is to be e(fective.
See reverse side (or additional instructions and qualifications. � E � �% 2�04
Taxing
(owner
�.J�./� r '
Assessed value of real properry as of
March 1, currenl year
If no, what is his / her exad share of interest?
If name on record is different than ihat of
of mortgagee or coniraIX
�
Key number
0(3-c
Mortgage / Contract ir
March 1, currenl year
indicate below:
\�' �l � /m Page number � �
J ,C W
�tedness unpaid as of Is ihe applicant the so
O^ owner? ❑ Yes
7`\ i
\.J
legal or equitable
❑ No
If owned with someone other than spouse, indicate with whom.
Address of mortgagee or contrad seller (number and sf�eet, city, state,
Name of assignee or other owner or holder of mortgage
of assignee (num6er and st�eet, city, state, ZIP code)
Does applicant own property in any other I If yes, what counry? What Taxing Distrid?
wunty in Indiana?
20
approved in the amount of:
20
,�
COUNTY AUDITOR
20 �� 20 �� 20
P �
Counry Auditor
� Real Property ❑ Mobile Hm�e (IC 61.1-�
Has this deduction been requested on
propeAy for wrrent year?[� Yes� No
�
Date
20
certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
ient of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
i res�aenc �aaares�s/Jor appupm ° Address of authorized person
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