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STATEMENT OF MORTGAGE OR CONTRACT INDI
- � FOR DEDUCTION FROM ASSESSED VALUATION
t � Slate Form 43709 (R4 / 10-01)
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� P�escribeA by DeDartment of Loral Govemment Finance
INSTRUCTIONS:
To be (led in person or 6y mail with the County Auditor of the county where the property is
Filing Dates: 1) Real Property: Dunng the 12 months be7ore May 11 0l the year the deduction is to be�tiJle.3 2�03
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 31 of the year the dedn�ction is to be eflective.
See ieverse side /or additional instructions and qualifications. � /(/� // n
Appliwnt(own ror ort2ct uyer-see
Taxing Distrid
Assessed value of real property as of
March 1, curtent year
16 no, what is his / her exad
side)
Key number / I�ga�description Record number �
� 13 .�� 2�� � Page number r I
✓ ,�
Mortgage / Contrad indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, curtent year , owneR ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
If name on record is different than ihat of applicant, indicate below:
'ame of moAgagee or contract seller
S� -� ,
Address ot mortgagee ar contrad seller (number and street, p, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sGeet, city, state, ZIP code)
Does applicant own property in any other I If yes, what county?
munty in indiana?
20
�
Signature
approved in the amount of:
20
�. .
What Taxing Distrid?
COUNTY AUDITOR
20 /7(c I 20 �% I 20
P �
County Auditor
s the property in question:
❑ Real Property � Mobile Horne (IC G1.
Has this dedudion been requesled on
property for curtent yeaf? � YesO No
20 �� 20
�
Date
�I/ We certify under the penalty of peryury that the above and foregoing infortnation is true and correcl and that ihe applicants was / were
a resident of Indiana and owner of the aforementioned property on March 1, 20
Sign re (o� erag (ull name) Person authorized by duly execuled Power of Attomey
� �, ,G � . � � or by IC 6-1.1-12-.07
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of aulhorized person