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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Stata Fwm 43709 (RS / 4-03)
Prescribed by Department of Local Govemment Finance
Coun Township Year
�RUCTIONS: File Mark
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months 6efore May 11 of the year the deduction is to be elfective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Maret'H-?,�of•theyear fAe de �is to be eBective.
See reverse side for addifional instruc[ions and qualifications. y"+ ���
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Applicant (owner or contract b see
Taxing District
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Assessed value of real property as of
March 1, current year
If no, what is his / her exacl share of interest?
Key number / legal
j1 // � � �Q �a Page number �� �
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ortgage / Conlract indebtedness unpaid as of Is the applicant the sole legal or equitable
arc6�9Fcurtent year owner? ❑ Yes ❑ No
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If name on record is diHerent than that of applicant, indicate below:
Name of mortgagee or contrect seller �.�/�
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If owned with someone other than spouse, indicate with whom.
of mortgagee or contract seller (number and street, city, state,
of assignee or other owner or holder of mortgage
of assignee (number and sLeet, crty, state, Z/P code)
Does applicant own property in any oiher I If yes, what counry?
COUfI[y �^.�^diana?.
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Deduc
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Card NO. , G3 � �� ��
What Taxing District?
OUNTY AUDITOR
20 � 20 ��
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Counry Auditor
❑ Real
❑ Mobile Home (IC Cr1.
Has this deduction been requested on
property for current year? 0 Yes ❑ No
20 �_
�
Date
20
1/ We certify under the penalty of perjury that the above and foregoing infortnation is true and conect and that the applicants was / were
a resident of Indiana and owner of the aforementioned property on March 1, 20
nt address of applicant
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Person authorized by duly executed
or by IC 6-1.1-72-.07
person