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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun T i Year
S�� / State Form 43709 (R5 / 4-03)
� PrescnDed by Department ol Loral Guvemment Finance
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INSTRUCTIONS: File "
To be filed in person or by mail with the County Auditor o/ the county where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 months before May 11 0/ the year the deduction is to be � Tv AUDIT�R
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Maich 2 0/ the r��iit is to be effective.
See reverse side /or additional instructions and qualifrcations.
Applicant (owner or cont�act
Taxing Dislrid
Assessed value of real property as of
March 1, cunent year
tions on revers� e)
6
Key number / legal descripiion
0�- oc
Mortgage / Contrad ir
March 1, current year
Record
number
- � .�
unpaid as of Is the applicant the�° le legal or
owneR [L�f'es ❑ No
�
if no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
. ,�� �I - 7 `Is '7
If name on record is different than that of applicant, indicate below: Is the p perty in question:
❑ eal Property ❑ Mobile Home (IC 61.
�ne of mortgagee or contrad seller ��
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Address of moAgagee or contrad seller (number and street, crty, state, ZIP ��"�
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Name of assignee or other owner or holder of mortgage
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Address of assignee (numberand street, city, state, ZIP code) �rawer L' �Q.,,.• •'
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Does applipnt own property in any other If yes, what county? � Ca�a����..���1 i°�� _.,,,n been requested on
county in Indiana? �„crty for wrrent year? � Yes❑ No
COUNTY AUDITOR
Deduction approved in lhe amount
zo
Signature
We certify
2o n� � 20 �_ zo 0 9 20 2o zo
P � �
County Auditor Date
r��t e penalty of perjury�t the above and foregoing information is true and correct and that the applicants was / were
ia and owner of the a ementioned property on March 1, 20
i .
full name � Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07 .
of authorized person