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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNES�
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (RS / 4-03) �
PresaiDed py Department of Lotal Govemment Finance
INSTRUCTIONS:
To be filed in person or 6y mail with the County Auditor of the county where the property is
Filing Dates: 1) Real Property: During the 12 months 6e%re May 11 0/ tbe year the deduciion is to be e C e ����
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the yea i i o be effective.
See reverse side for additional instructions and quali�cations.
_ n � ��'��
(owner or contract
Taxing Distrid
resMctions on
Key number / legal
Record number
�.�e���'(,(.v�-L.i� � /� Oda�Q--�Q Pagenumber ��/
10
Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owner? ❑ Yes ❑ No
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If no, whal is his / her exad share of interest?
If name on record is different lhan fhat of applicant,
of mortgagee or conlract seller
below:
of mortgagee or contract seller (number and s12et, cify,
or other owner or holder of mortgage
owned with someone other than spouse, indicate with whom.
ZIP
Address , ♦ � :ode)
Drawer NO...O•�•••��� �
Does apF � ty? What Taxing District?
county in
CardNO . .....................
COUNTY AUDITOR
approved in the amouni of:
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Signature
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County Auditor
Is
❑ Real Property ❑ Mobile Home pC 61.7-�
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Has this dedudion been requested on
property for wrrent year?� Yes❑ No
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certify under the penalty of perjury that the above and foregoing information is true and corred and thai the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
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address of,
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Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person