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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
S / State Form 43709 (RS / 4-03)
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� PrescribeE by Department of Local Govemment Finance
INSTRUCTIONS:
To 6e filed in person or by mail with the County Auditor of the county where the property is located. a p� 6 2��4
Filing Dates: 1) Real PropeRy: During the 12 montAs before May 11 of the year the deduction is to 6e eBective.
2J Mobile Homes assessed under IC 6-1J-7: Between January 15 and March 2 0/�t�Ae year the dedu(c�tion is ton be neffective.
See reverse side for additional instructions and qualifications. ./K,�� �, /i // l/
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Applicant (owner or cont y�r- see res c' ns n reverse side)
Taxi istrid Key number / legal descripiion Record number �
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Assessed value of real prope as of Mortgage / Contrect indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, cunent year March 1, current year owne(? ❑ Yes ❑ No
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If no, what is his / her exad share of interest? If owned with someone ather than spouse, indicate with whom.
If name on record is different lhan thal of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC G1.1-�
'ame of mortgagee or contrad seller
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Address of moRgagee or contract seller (number and st2et, city, st e, ZIP
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Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does appliwnt own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for wrrent yeaf? � Yes 0 No
COUNTY AUDITOR
Deduction approved in the amount of:
20� 20 Q!p__ 20 20 D� 20 � 20 20
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Signature County Auditor Date ,
�I/ We certify under the penalty of perjury that the above and foregoing information is true and corred and that ihe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
S gnat e(owner's ame) Person authorized by duly executed Power of Attomey
� ' or by IC 6-1.1-12-.07
Full s' ent address of applicant /. Address of authorized person
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