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'� i�� STATEMENT OF MORTGAGE OR CONTRACT IND�BTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
J State Fwm 43709 (R6 / 5-06)
� Presaibed by Departmen� of Laal Govemment Finance
Count Township Year
INSTRUCTIONS: File Mark
To be filed in pe�son or by mail with the County Auditor o/ the counfy whe�e the property is located.
Filing Dates: 1) Real P�operty: DuAng the 12 months be(ora June 17 0/ the year the deduction is to be effective.
2J Mobile Homes assessed unde� IC 6-1.1-7: Between January 15 and March 2 o/the yea�e�U n i� �e.
See reverse side for additional instiuctions and qualifications.
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Applicant (obt�i�r or contract buyg^- see rest�iitions on reverse side)
Taxing Distrid V (/� Key�umber / legal description Record
/ �%J����?%�L�[. Q� I Page ni
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AUDITOR
a�-�a6-�vo-�a.�s�,� 7d7G
Assessed value of real property as of Mortgage / Contract indebtetlness unpaia as oT I is the applicant the sole legal or equitable
AAarrh 1,'curtent year March 1, current year � ownef? ❑ Yes � No '
If no, what is his / her exacl share
If name on record is diHerent than ihal of applicant,
below:
If owned with someone other than spouse, indicate with whom.
�e of mortgagee or contrad seller � ��
Address of mortgagee or contrad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county?
county in Indiana?
Deduction approved in the amounf of:
20 �/�
�
Signature
20 �_ I 20
V
What Taxing District?
COUNTY AUDITOR
20 20
County Auditor
Is lhe property
❑ Real Prooer
� Mobile Hort�e (IC 61.
V
Has this dedudion been requested on
property for current yeaR �] Yes 0 No
20
Date
20
We certify under the penalty of perjury that the above and foregoing information is true and correc[ and lhat the applicants was / were
esideM of Indiana and owner of the aforementioned property on March t, 20
(owners Iull
r
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
applicant �Address of authorized person