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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Slale Fortn 43709 (R4 / 10.01)
PrescribeC by DepartmeN ol Loral Govemment Finance
INSTRUCTIONS:
�o be tuetl in person or by mail wlth the Gounty Auditor o! the county whe2 the propeRy is located.
Filing Dates: 1) Real Property: Dunng the 12 monfhs be%ie May 11 0l the year the deduction is to �g(�{f�ctive. 2��2
2) Mo6ile Homes assessed underlC &1.1-7: Between January 15 and March 31 0l lhe yea� fhe deduction is to be e/%ctive.
See reverse side Ior additional instructions and qualifica6ons.
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Applicanl (owneror co ct buyer- see 2striction reverse side)
Taxing Districl Key nu ��al description Record number O�
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� � � �/�1`�il Page number / _ ��
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Assessed vatue of real property as of Mortgage / Contrect indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, current year ' owner? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is different than lhat of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home QC fr1.1-�
� e of moAgagee or contract seller
Address o( mortgagee or contrad seller (number and sfreet, , state, ZIP
Name of assignee or other owner or holder of mortgage '
Address of assignee (number and street, city, state, ZIP code)
Does applicant own propeRy in any other I( yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for wrtent yeaRO YesO No
COUNTY AUDITOR
Deduction approved in the amount of:
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Sign ure County Auditor Date
We certify under the penalty of peryury that the above and foregoing information is true and corred and that the applicants was / were
sident of Indiana and owner of the aforementioned property on March 1, 20
Sig a e ne (ull name) Person authorized by duly executed Power of Attorney
, or by IC 6-1.1-12-.07
F s� ddress of applicant � Address o authonzed person
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