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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R6 / 5-OG)
Presaibetl by Depariment of Loml Gmemment Finance
INSTRUCTIONS:
To be (iled in person or by mail wifh the County Auditor of the county where the prope�ty is
Filing Oates: 1) Real PropeRy: During the 12 months 6efo2 ,lune 17 of the year the deduction is to� p�f,qftl�e.�007
2) Mobile Homes assessed under IC 6-7. 7-7: Between January 15 and March 2 of th ��i tlfe e uct�on is to be eflective.
See �everse side for additional instructions and qualifrcatrons.
(owner or
Tauing Distrid
�.Y i '
C� �'(..��--
Assessed value of real property as of
March 1, current year
what is his / her exad share of interest?
on
�6� ,6,
Key number / legal description rd�i umber
�?G-/9—/8-,303�000: b'iv-a,,� � �
//� //_O � Q� [/-0%� agenumber �
v r p 7 v
Mortgage / Contrect indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, currenl year owne(? ❑ Yes ❑ No
3o b'c7
If owned with someone other than spouse, indicate with whom.
If name on record is dif(erent ihan iliat of applicant, indicate below:
�me of mortgagee or contrad seller ,/y/�
/ '
(
Address of mortgagee or contract seller (number and stieet, city, stafe,
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP crode)
Does applipnt own property in any other If "T �-� Taxing Distnct?
counry in Indiana? S E� µ ��ET
E�
ul�GCy
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Dedudion approved in the amount of:
20 � 20 �_ 20 y�� 20 20
%� T fo
County Audiror
s the property in question:
❑ Rea�Property� ❑ Mobile Home QC 61.1-�
Has this deduction been requested on
property for current year? 0 Yes� No
20
Date
20
We certify under the penalty of perjury lhat the above and foregoing information is true and corred and ihat the applicants was / were
resident of Indiana and owner of lhe aforementioned property on March 1, 20
Person authorized by duty executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person