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i``��STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION T(�^ownship Year
��j z Stale Fortn 43709 (R6 / 5-06) ��
� Presaibed by �epartmenl of Local Govemment Finance �
NOV 1 5 ,0(��
INSTRUCTIONS: � F7e fOFark
To be filed in pe�son or by mail with the County Auditor of the counly where [he property is located.
Filing Dates: 1J Real P�operty: During the 12 months before June Il o( the year the deduction is lo be � ,6
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/�1@$� �� �i � is to 6e el%ctive.
AUDITOR
See reverse srde for additional instructions and qualifications.
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1�
or
Taxing D�€trid U'
����- ���.
Assessed value of real property as of
March 1, current year
If no, what is his / her exact share
on reverse
Key number / legal c(escription Record number
�G /�2 /G_�o/-����5%oa7 O�
�P _ O/a /7.� � Page number ���/
/
MoAgage / Contrad indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, currenl year owneR ❑ Yes ❑ No
F-�� I
If owned with someone other than spouse, indicate with whom.
If name on record is different than that ot applicant, indicate below:
!me of mortgagee or conVact seller �
Address of moAgagee or conVad seller (number and tieet, ciry, state, ZIP
Name of assignee or other owner or holder of mortgage
of assignee (number and st2et, crty, state, ZIP code)
Does applipnt own property in any other I If yes, what county?
counfy in Indiana?
❑ Real Properly ❑ Mob'le Horrie QC 61.1-�
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COUNTY AUDITO
)edudion approved in the amouni of:
20 � 20 �� 20 �_ 20
� � P
Signature
County Auditor
�Z�7
20
Dale
20
ssled on
'es � No
We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
resident ot Indiana and owner of lhe aforementioned property on Marcli 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person