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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Slate Fofm 43709 (R4 / 10.01)
PresaibeU by Depariment of Local Govemment Finance
ULY E
Subject to
INSTRUCTIONS: day of Fil rk �_
To be filed in person or by mail with the County Auditor ol the county where the property is locafed. I"IAK 1 �
Filing Dates: 1) Real Property: During the 12 months belore May 11 0/ the year the deduction � fo be ectrv . AUd;tor
2) Mobile Homes assessed under IC &1.1-7: Between January 15 and March 3 F� �� �ucti,7i�,�� pg�� cti .
See reverse side /or additional instn�ctions and qualifications. Parcel � ��r°nl �urv ti i�
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Appliwnt (owne con ract buy r- see restri 'ons on reverse side)
Taxing Distrid Key number / legal description Rewrd number
0
� �A� Page number n^ ` I
d "[' ! 1
Assessed value of real property as Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owneR ❑ Yes ❑ No
If no, what is his / her exact share of inlerest? If owned with someone other than spouse, indicate with whom.
If name on record is different ihan that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home QC 61.1-�
' me of moRgagee or contrad seller �
Address of mortgagee or conlract seller (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP code)
Does applicant own property in any other If yes, what counry? What Tauing Distrid? Has this deduction been requested on
counry in Indiana? property for current yea(? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 09 20 D 20 0 7 20 �l� 20 20 0 Y 20 ��
Prfl aa,� � � f' P
Signature County Audftor Date
�/ We ceAify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
� resident of Indiana and owner of the aforemenlioned property on March 1, 20
Si alure (avners lull name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
F dent dress of applipnt Address of authorized person
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