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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
� FOR DEDUCTION FROM ASSESSED VALUATION
�`+ � ♦ Stata Form 43709 (R5 / a-03) � � .
� PresaiDed by Department of Laal Gtivemment Finance
INSTRUCTIONS:
To be �led in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1 J Real PropeRy: Dunng the 12 months before May 11 o/ the year the deduction is to 6e eHectiv�.�� �O � Cp��
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the yea�r the� UT' ction is4 Hective.
See reverse side for additional instructions and qualifications. /�]/ /( U/, nn n�
Applicant (owner or contract buyer- see resMctions on verse ide)
Taxing Dislrid Key number / legal des rip ion
� ('�O.3S •(
Assessed value of real property as of MoAgage / Contract indebtedness
March 1, curtent year March 1, wrrent ye2r
If no, what is his / her exacl share of interest?
It name on record is different than that of applicant,
of mortgagee or contrad selier
of mohgagee or coNract seller (number and street,
Name of assignee or other owner or holder of moRgage
Address of assignee (number and street, city, state, ZIP
Does applicant own property in any other I If yes, what county?
county in Indiana?
Deduction a
20 �(�
�
Signature _
in the amount
20 O 1 I 20
as
Record number
Page number
is the aDP���nt the sole legal or equitable
ownef? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
ZIP
1�Via[ Taxing Distrid7
COUNTY AUDITOR
�li"�m
�_P
_ County Auditor
s the property in question:
❑ Real Prope�iy p Mobile Home (IC 61.1-�
Has this dedudion been requested on
property for current yea(? � Yes � No
zo
Date
20
certify under the penalty of perjury that the above and foregoing information is We and corred and that the applicants was / were
�len ot Indiana and owner of the af ementioned property on March 1, 20
owne�S full nam '_(1 Person authorized by duly executed Power of Attorney
( I � or by IC 6-1.1-12-.07
Address of authorized person