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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Slate Form 43709 (R4 ! 10-01)
PresaibeA by Depanmenl ot Local Gavemment Finance
INSTRUCTIONS:
To be filed in person or by mail witb the County Auditor o( the county where the property is locareo.
Filing Dates: 1 J Real Property: During the 12 months be%re May 11 oJ fhe year the deducfion is to be e8ective. i u0�
2) Mobile Homes assessed under IC 6-1.1J: Befween January 15 and March 31 of the yea� the �deduction is to be eHective.
See reverse side !or additional instructions and qualifications. I�� � r
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Applicant (own97�orcon� buyer- re M UOns o v si )
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Taxing Dislrid Key numbe / legal desaiption Record number p� �
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Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, a,lrtent year 5H 36� , 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 that of applicant, indicate betow: Is the property in queslion:
❑ Real Property ❑ Mobile Hortie (IC 61.1-�
�me of moAgagee or contrad seller � ?
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Address of mortgagee or conVact seller (number and s reet, city, state, ZIP
Name ot assignee or other owner or holder oi mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Tauing Distrid? Has lhis deduction been requested on
county in Indiana? property for currenl year? � Yes � No
COUNTY AUDITOR
Deduction approved in the amount of:
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Signature County Auditor Date
'/ We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the appliranls was / were
� resident of Indiana and owner of the aforementioned property on Marcn 1, 20
Signatur (o n s 11 am Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
ull resi n d re f ap lipnt Address of authorized person
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