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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
-° � FOR DEDUCTION FROM ASSESSED VALUATION
Sf �- y State Form 43709 (R4 / t P-07 )
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� Prescribe0 by DepaNnent ol Lora1 Govemment Finance
INSTRUCTIONS:
To 6e filed in person or by mail with fhe County Audifor of the county where the praperty is located. �I
Filing Dates: 1) Real Property: During the 12 months 6e1o2 May 11 of the year the deduction is to be efY U�ve� 1 Z00
2) Mobile Homes assessed under IC 61.1-7: Between January 15 and Maich 31 0/ t year the deduction is to e e//ffective.
See reverse side lor additional instructions and qualifica6ons. %��JL.. . _,..� 1
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Applicant (o er r crontract buyer - s restrictiows on revease ' e)
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Taxing Distri Key number / legal description Record number��
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Assessed value oi real property as af MoAgage / Contrad indebtedness unpaid as of Is the applipnt the sole legal or equitable
March t, current year March 1, curren year owneR ❑ Yes ❑ No
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t? If owned with someone other than spouse, indicate with whom.
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If name on record is iHerent than lhat of applicant, indicate below: Is the property in queslion:
Real Propeity ❑ Mobile Home (IC G1.1-�
�me of mortgagee or contrad selier
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Address of mortgagee or contract seller (number and street, aty, st , ZIP
Name of assignee or other owner or holder ot mortgage
Address of assignee (number and st�eet, city, state, ZIP code)
Dces applicant own property in any other If yes, what county? VYhat Taxing Distrid? Has this deduction been requested on
county in Indiana? property for wrrent year? 0 Yes � No
COUNTY AUDITOR
Deduction approved in the amount of:
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Signature County Audilor Date
�/ We certify under ihe penalty of perjury lhat the above and foregoing information is true and corced and lhat the applicants was / were
: resident of Indiana and ow er of the aforementioned property on March 1, 20
Signature o ne/s full na ) . � Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
F II resident address of ap 'pnt A dress of authorized rson
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