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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Sfate Form 43709 (R4 / 10-01)
PrescribeA by DepaNrent of Local Govemment Pinance
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INSTRUCTIONS:
To be filed in person or by mail with the County Auditor o1 the county where fhe property is locat�y �q�3
Filing Dafes: 1) Real Property: During the 12 months belo2 May 11 of the year the deduction fs'f�'be »
2J Mo6ile Homes assessed under IC 6-1.1-7: Behveen January 15 and Marcfi�31 of the year th8 deduction "s to be effective.
See reverse side for additional instructions and qualifications. ��
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Applicant (ovmer or tra u r- see res[ ' ions o�ve d)
Taxing Distrid Key number / legal description Record number
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, cunent year March 1, �¢nt year owneR ❑ Yes ❑ No
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If no, what is his / her exacl share of interest? If owned with someone other than spouse, indicate with whom.
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If name on record is diHerent than that of applicant, indicate below: • ` Is the property in question:
❑ Real Property ❑ Mobile Hmie QC 61.1-�
�Name of mortgagee or contract seller „1
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Address of mortgagee or conVaIX seller (number and street, ci , st , ZIP �
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sfreet, city, state, ZIP code)
Dces applipnt own property in any other If yes, what counry? What Taxing Distrid'? Has this dedudion been requesled on
county in Indiana? property for current yeaRO YesO No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �_ 20 �� 20 � 20@�_ 20 �� 20 �_ 20 �_
8 � � � � �
Signature County Auditor Date
I/ We certify under the penalty of perjury that the above and foregoing infortnalion is true and coRed and that the applicants was ! were
� resident of Indiana and owner of the aforementioned property on March 1, 20
'�gnature.(pivners (ull na ) Person authorized by duly executed Power of Attomey
, or by IC 6-1.1-12-.07
ull resident address f applipnt Address of aulhorized person
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