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°� �° STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS '
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� : FOR DEDUCTION FROM ASSESSED VALUATION � o ship Year
'� J. State Form 43709 (R3 / 70.00)
Prescribetl by SWte Board of Tax Commissioners
File Mark
InsUuctions for filing:
To be fifed in person or by mait with the County Auditor of the county where the property is GI9SQtJ CO!'t:T; AUDITOR
located during the 12 months before May 11 of the year the deduction is to be effective. See
reverse side for additional instrudions and qualifications.
Applicant (owner o tract buyer - see restriction on reverse side)
Taxing Disfid Key number / I I description Record number O
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Assesse value of real property as of Mortgage / Contract indebtedness unpaid as ot Is the applicant the sole legal or equitable
March 1, current year March 1, current year owneR ❑ Yes ❑ No
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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 applicani, indicate below:
of mortgagee or wntrad seller � -
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Address of mortgagee or contract seller (number and stieet, city, state, ZIP
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Name of assignee or other owner or holder of mortgage
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Address of assignee (number and stieet, city, state, ZIP code)
Does applicant own real property in any If yes, what county? What Taxing District? Has this deduction been requested on
other county in Indiana? property for current year? � Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
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zo 01 20 � zo CI Zo zo ��E Zo c� 7 zo ��
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Sign ture d9 County Auditor Date
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��e certify under lhe penalty of perjury thal the above and foregoing information is true and correct and that the applicants was / were
sident of Indiana and owner of the aforementioned property on March 1, 20
S' nat r(owners lull name) Person authorized by duly executed Power of Attomey
� � or by IC 6-1.1-12-.07
I re nt address of appli t Address of authorized person
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