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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fam 43709 (RS / 4-03)
PresaiEeO by Department o1 Local Gtivemment Finance
Coun Township Year
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INSTRUCTIONS: File�lc
To be filed in person or by mail with the County Auditor of the counry where the property is /ocated. M�Y 2 L�
Filing Dafes: 1) Real Property: Dunng fhe 12 months before May 11 o1 the year the deduction is to be e/%ctive.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0! the year the deductio� is to ueffective.
See reverse side for additional instructions and qualifications. �� 45��� ,:��� �,�Tv .,� !TC"' �
Taxing Distrid •
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Assessed value of real property as of
March t, current year
If no, what is his / her exact
interest?
on reverse side)
Key number / legal description Record number aL7G �
— Pagenumber �/,L//
7
MoAgage / Contrad indebtedness unpaid as of Is the applicant t sole legal or equitable
March 1, current year owne(? Yes ❑ No
If name on recard is different than that of applicant,
of mortgagee or contrad
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If owned with someone other than
Address of mortgagee or contrad seller (number an�streef, city, state,
Name of assignee or other owner or holder of mortgage
of assignee (number and street, ciry, state,
Does applipnt own property in any other If yes, what counry?
counry in Indiana?
20
Signature
approved in the amount of:
20
Is
indicate with whom.
❑ Mobile Home QC 61.1-n
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Dra«�er NO..��.7.....'.
What 1 � �( / � � sted on
Card NO. ........!.Y es�No
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COUNTY AUDITOR
20 O•1 20 ('M
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County Auditor
20 �
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20
20
We certify under lhe penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
resident of Indiana and owner of the aforemenlioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
resident address of applipnt � �Address of authorized person