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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNE&�
FOR DEDUCTION FROM ASSESSED VALUATION
�. M/ State Fwm 43709 (RS / 4-03)
�� Presaibetl by Department of Lazl Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail wdh the County Auditor of the county where the property is
Filing Dafes: 1) Real Property: During Me 12 months before May 11 0l the year the deduction is to �e�eqti�.��1
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0! the �%e th� de an is to be effective.
See reverse side for additional insfructions and qual�cations. � /�� n n
(ownerorcontract
Key number / legal description I Record number
�b � _., Q��7� b -�'J� Page number /�/d /
�'
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, currenl year March 1, cuqepFy�a;�� ��� owner? ❑ Yes ❑ No
� �� oC
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 Ihan that of applicant, indicate below: Is the property in question:
_ ❑ Real Roperty ❑ Mobile Home QC G1.1-�
of mortgagee or contrad seller
Address of mortgagee or contrad selier (number and street,
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand sUeet, city, st��- "�
Does apoi��'
���c. Dra,verl`��• 0'�•-
Card r}p.
20
Signature
20
.9.1Z�
de)
.—,
state, ZIP
What Taxing District?
INTY AUDITOR
20 QZ 20 Q�
P
County Auditor
Has this dedudion been requested on
property for current year? � Yes ❑ No
20 G�+ 20_
�°
Date
20
We certify under the penalty of perjury lhat Ihe above and foregoing information is true and corred and ihat the applicants was / were
�esident of Indiana and owner of the aforementioned property on Marcli 1, 20
�fur wners (ull name) Person authorized by duly executed Power oi Attomey
� J_���_..._ � o� bY �� 6-,_,-,z-.o�
address of applicant Address of authorized person
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