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rt"� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
- FOR DEDUCTION FROM ASSESSED VALUATION
1 � St3te Fortn 43709 (R4 ! 10-01)
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� Prescribe0 by Department of Local Govemment Finance
Coun Township Year
•
INSTRUCTIONS: File Mark
To 6e filed in person or by mail with the County Auditor of fhe county where the property is located.
Filing Dates: 1) Real Property: During the 12 months befo2 May 11 0l the year the deduction is to be effective.
2) Mobile Homes assessed under IC 61.1-7: Belween January 15 and March 31 0/ the year the�j�Ae�duction�is to�De-efle �v
See reverse side for addi6onal instructions and qualifications. {f"'� ����
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(owne� or contract bu`c�'- see
number / legal description
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4 O 1- aao l(�� Page number ^� �
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Assessed value ot real property as of Mortgage / Contract indebtedness unpaid as of Is the appliqnt the sole legal or equitable
March 1, current year March 1, currenl year ownef? ❑ Yes 0 No
3 S �t0�
If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
of mortgagee or contract seller
Address of mortgagee or conVad selier (number and stieet,
of as
Does applicar
county in Indi�
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Deduction approved in the amounl of:
20 jL,�
Signature
20
tgage -
e, ZIP code)
ihatcounty?
ZIP
What Taxing Distrid?
COUNTY AUDITOR
20 20 �_ 20
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County Auditor
Is the property in question:
❑ Real Property ❑ Mobile Home QC 61.
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Has this dedudion been requested on
property for wrrent yeaR � Yes � No
20 O'1 20
�
Date
We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and lhat the applicants was / were
resident of Indiana and owner of the aforemenlioned property on March 1, 20
Person authorized by duly executed
or by IC 6-1.1-12-.07
Full resiQ�"nt address of applip6t Address of authorized person
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