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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (RS / 4-03) � �; " � ,
PrescnDed Gy Depanmeni of Loral Gtivemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is locate� � ����4
Filing Dates: 1J Real Property: During the 12 months before H1ay 11 o/the year the deduction rs�f e fle
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Marc/p,-2 0! the ye/ar th[e�'rleduction is o be elfective.
See reverse side for additional instructions and quali�cations. `�(�� �yy, ,/',�� . 1 .
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Applicant ( orcontract b r- trictions on verse ' e)
Taxing Distrid Key number / legal description Record number O�
OV/�C/aa��� Pagenumber !� r-��
�Y a a
Assessed value of real property as of Mortgage / ContreU indebtedness unpaid as of Is the applicant the sole legat or equitable
March 1, wrrent year . March t�urrent yeer owner7 ❑ Yes ❑ No
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If no, what is his / her exad share of interest? . If owned wifh someone other tha� spouse, indicate with whom.
If name on record is different than thal of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home QC 61.1-�
�me of mortgagee or contracl seller
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Address o( moAgagee or contrad seller (number and street, ity, state, �
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Name of assignee or other owner or holder of mortgage `� �
Address of assignee (number and street, ciry. �tate, ZIP code) .
Does applicant own property in any other It yes, what counry % ( l^�fiat Taxing Districl? Has this deduction been requested on
county in Indiana? � property for current yea(? n Yes ❑ No
I
COUNTY AUDITOR
Deduction approved in the amount of:
20 0 20,(J�l _ 20 _ 20 _p� 2D �_ 20 20
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Signature County Auditor Date
��/ We certiy under the penalty of perjury ihat the above and foregaing information is true and corred and that the applicants was / were
sident of indiana and owner o( the aforemer.tioned property on March i, 20
Signatur o ners full r e) Person auihorized by duiy exewted Power of Attorney
.1'/_lRA"!�� or by IC 6-1.1-12-.07
w
ull resident address of applicant Address of authorized person
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