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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNES�
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R5/4-03) �
Prescri�eA Oy Deparimant of Loc�al Govemment Finance
INSTRUCTIONS: p
To be filed in person or by mail with the County Auditor of the counry where the propert�y is
Filing Dates: 1) Real Property: During fhe 12 months before May 11 0/ the year the deduction�is�to
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2�0% the
See reverse side (or additional instructions and qualifications.
see restrictions on
Distrid
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Assessed value of real property
March 1, current year
no, whal is his / her exact share of interest?
Key number / legal
deductian is to be effective.
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� O� _/^ / � ll Q � Page number �� �
lJ � 7 �
Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or
March 1, current year ownef? ❑ Yes ❑ No
If name on record is difterent than lhat of applicanl, indicate below:
mortgagee or contrad seller
If owned with someone other than spouse, indicate with whom.
Address of mortgagee or contrad seller (number and stieet, city, state,
Name of assignee or other owner or
Address of assig
Does applicant a
county in Indian�
mortgage
O � - 3���
Dra�r�er, i\TO ...................
Card NO . .....................
Deduction approved in the amounl
20
SignaWre
20 {��
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What Taxing Distrid?
f AUDITOR
20 C )�I 20 ��
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County Auditor
20
❑ Real Property ❑ Mobile Home QC E1.1-�
Has lhis deduction been requested on
property for current yea(? � Yes � No
20
Date
20
/ We certify under the penalty of perjury lhat the above and foregoing information is true and corred and that lhe applicants was / were
resident of Indiana and owner of the atorementioned property on March 1, 20
(owner's full
�iGent addy�$s�f applicant '
r,�3 �,� yz �,
Person authorized by duly executed Power of Attomey
or by IC 6-7.1-12-.07
of authorized person