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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES�
FOR OEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (RS / 4-03)
Presoibed Ey Depertment of Local Govemment Finance
�rRUCnorvs:
� be filed in person or 6y mail with the CounryAuditor of the county whe2 the property is �V V J
Filing Dafes: 1) Real Property: Dunng the 12 montbs be%re May 11 of the year the deduction is to be e�c�ivel `�.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and MaicA 2 0l the year the deduction is to be e(%ctive.
See reverse side for additional inshuctions and qualificatrons. �.�� }��,, ��
Cs1B�Ct1 Gr: l:C •� OtTO� �
Ap icant (owner or contract buyer Z
Taxing District
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Assessed value of real property as of
March 1, current year
If no, what is his / her exact share of interest?
If name on record is different than that
Name of mortgagee or contract seller
Key number / legal desuiption
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Mortgage / Contract indebtedn
March 1, current year
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Record nu � r Z �
`J
_ Page number
Is the applicant the� ole legal or equitable
owner? C�es ❑ No
If owned with someone other than spouse, indicate with whom.
a¢erty in questian:
Property ❑ Mobile Home (IC E1.1
ot mortgagee or contrect seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street,
Does applicant own property in any
county in Indiana?
Deduction approved in the amount of:
20
Signature
state,
If yes, what c (� - - "-""-�a^-'°<<��� hoen.reouested on
\��I �?c--. � � �� � YesO No
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20 � � 20
G
I/ We certify under the penalty of perjury that the ab
a resident of Indiana and owner of the aforemention
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BOISE. IT COULDNT BE EASIER:
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IPerson auu����«...., _-•, ---
or by IC E1.1-12-.07
resident address of applicant �Address of authorized person
was / were
1