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� i"" '� STATEMENT OF MORTGAGE OR CONTRACT INUEBTEDNESS
a' � FOR DEDUCTION FROM ASSESSED VALUATION
�.,«. / State Fortn 43709 (R6 / 5-06) � . .
Presaibed by Deperimem of Laal Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor ot the county whe�e the property is located. ��� �%�
Filing Dates: 1) Real Property: Dunng the 12 months before June Il o/ the yea� the deduction is to be effecJive. Z�OI
2J Mobile Homes assessed under IC 6-1J-7: Between January 15 and March 2 of the yea� �p�1.uc��to be effective.
See reverse side lor additional instructions and quali�cations. "'BjC;+ C�� TY qUDITOR
Applicant (owner or ao� ct buyer- see restridions on reverse side)
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Taxing Distrid Key number / legal description Record number
d00 7
� �b-la-ISr-3ol•0o/.'�Z2-o�.7 Pagenumber �00�
Assessed value of real praperry as of Mortgage / Contred indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, current'year owner? ❑ Yes ❑ No
/5ygoo
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 diHerent than that of applicant, indicate below: , Is the property in question:
❑ Real Property ❑ Mobile Horne pC 51.1-�
e of moAgagee or contrad seller
� "
Address of mor�qagee or co � act seller (number and st2et, city, state, ZIP
Name ol assignee ar other owner or holder of mortgage
Address of assignee (num6er and street, city, state, ZIP code)
Does app6cant own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for wnent year?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 OR 20�9 20 20 20 20 20
P e
Signalure County Aud'Aor Dale
We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and lhal the applicants was / were
resident of Indiana and owner of lhe aforementioned property on March 1, 20
Signat� (� rs name) Person authorized by duty executed Power of Attomey
�/ or by IC 6-1.1-12-.07
.i
Full resident ad r ss of applicant Address of authorized person
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