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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNFcc
-- FOR DEDUCTION FROM ASSESSED VALUATION
S � Slate Form 43709 (R4 / 10-01 j
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� � Prescribetl by DepaNnent of Loral Govemment Finance
INSTRUCTIONS:
To 6e filed in person or by mail with the County Auditor of the county where the propeRy
Filing Dates: 1) Real PropeRy: During the 12 months before May 11 of the year the deduction is to�ne �ectii�03
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 31 of'the year the deduction is to be eflective.
See reverse side (or additional inshuctions and qualifica6ons. �` / �j �% �
Applicant
Taxing
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Assessed value of real property as of
March 1, current year
no, what is his / her exact share of interest?
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Key number / legal description
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Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitabie
March 1, current year owner? ❑ Yes ❑ No
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If owned with someone other than spouse, indicate with whom.
If name on record is diiferent ihan thaf of applicant, indicate below:
�me of mortgagee or contrad seller
Address of moAgagee or contract seller (number and street, city, state, ZIP
Name oi assignee or other owner or holder of
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other I If yes, what wunty? What Taxing District?
county in Indiana?
Deduction approved in the amounl of:
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Signature
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COUNTY AUDITOR
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County Auditor ,
� Reai PropeAy ❑ Mobile Home (IC 61.
Has this dedudion been requested on
property for current yeaR � Yes❑ No
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Date
/ We certify under the penalty of perjury that the above and foregoing infortnalion is true and correcl and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
applipnt
�. --`
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
person