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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�'. N. � State Fomi 43709 (RS / 4-03) .
� Prescribed by Depertment of Local Govemment Finance
Coun Township Year
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INSTRUCTIONS: ,File t
To be filed in person or by mail with the CotintyAuditor of the county wheie the property is located. F E g���T
Filing Dates: 1) Real Property: During the 12 months be%re May 110) the year the deduction is to be-e/%ctive.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction'is to
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See reverse side for additional ins[ructions and qualifications. /:""" ���-�"`' �
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6uyer ; see �stnctions on
Taxing
Assessed v!(ue of real property as of
March 1; wrrenf year
Key number /
OD y- drs9a- �
Record number
Page number
MoAgage / Contrad indebtedness unpaid as of Is the a
March 1,�urrent year owner?
lyo3
t the sole legal or
❑ Yes ❑ No
If no, what is his / her exact share of inlerest? If owned with someone other than spouse, indicate with whom.
If name on record is different ihan that of applicant, indicate below: Is the pr in question:
Real Property ❑ Mobite Home QC G1.
�me of moAgagee or contred seller
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Address of mortgagee or contract seller (number and sfreet, city, state, ZIP - -
Name of assignee or other owner or holder of mortgage
of assignee (num6er and street, city, state, ZIP
Does applicant own property in any olher I If yes, what wunty?
county in Indiana?
approved in the amount of:
20 �_
1
Signature _
20
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What Taxing Di � on
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COUNTY AUDITOR
20 �� 20 � 20
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Counfy Auditor
20
Date
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We certity under the penalty of perjury that the above and foregoing information is true and corred and that ihe applicants was / were
�esid t of ' a and owner of the af entioned property on March 1, 20
ur ners fu I na Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
Address of authorized person