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e.��° STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
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af : FOR DEDUCTION FROM ASSESSED VALUATION
t, �J Slate Fofm 43709 (R4 / 10.01)
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Prescribe0 by Departnent o! Local Govemment Finance
INSTRUCTIONS:
To 6e filed in person or by mail with the County Auditor of the county where the property is lo�
Filing Dates: 1) Real Property: Dunng fhe 12 months be%�e May 11 0/ the year the deduction is to q� ��cEyve. ���
2) Mo6ile Homes assessed under IC 6-1. 7-7: Behveen January 15 and March 31 0/ the�i� t/re de n is to 6e effecfive.
See reverse side /or additional instructions and qualifications. � /�� n n
buyer-see�
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Taxing Disfrid
Assessed value of real property as of
March 1, current year
on reverse
Key number / legal description Record number
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Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owner? ❑ Yes ❑ No
If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
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If name on record is different lhan that of applicanl, indicate below: Is e property in quesfion:
❑ Real Property ❑ Mobile Home (IC 61.1
me of mortgagee or contrad seller
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Address of moAgagee or wntrad selier (num er and street, city, 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 property in any olher If yes, what county?
county in Indiana?
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Deduction approved in the amount of:
20� 20 20 20
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Signature County Auc
What Taxing District?
NTY AUDITOR
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Has this dedudion been requested on
property for wrrent year?� YesO No
20 �_ 20 �
Y �
Date
We certiry under the penalty of perjury that the above and toregoing information is true and corred and that lhe applicants was / were
resident of Indiana and owner o(the aforementioned property on March 1, 20
�ature (owners full name) Person authurized by duty executed Power of Attorney
Q/�— Q or by IC 6-1.1-12-.07
resident address of applicant �Address of authorized person