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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Sute Fwm 43709 (R5/4-03) �
Prescnbed by Depanment of Local Govemment Finance
INSTRUCTIONS:
To 6e filed in person or by mail with the County Auditor of the county where the property is located. �1
Filing Dates: 1) Real PropeRy: Dunng the 12 montbs be%re May 11 0/ the year the deduction is to be eKectiv�� � 0 y 2004
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the yea !�e deduction is be effective.
See reverse side /or additional instructions and quali�cations. �
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Applicant (owner or contract buy ee restnctions on� e s
Taxing Distrid � Key number / legal escription Record umber O
6!(� �� O�p\ � S d Q Page number
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Assess d value oi real property as of Mortgage / Conired indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year ownef? ❑ Yes ❑ No
Q O �
If no, what is his / her exact 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: Is the property in question:
❑ Real Property ❑ Mobile Hm�e (IC 61.1-�
�me of moRgagee or contrad seiier A ,
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Address of mortgagee or wntrad seller (number and s et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, sfate, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for wrrent year?Q Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
Zo zo zo � Zo D io zo zo
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Signature County Auditor Date
/ We certiy under the penalty of perjury that the above and foregoing information is true and correc[ and that the applicants was / were
asident of Indiana and owner of the aforementioned property on March 1, 20
ignatur (owners full nam ) Person authorized by duly executed Power of Attomey
� or by IC 6-1.1-12-.07
res ent address of appli nt Address of authorized person
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