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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION �{ ��hi Year
� Stata Fortn 43709 (R5 / 4-03) � fi ' f ,
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PresaiDed 6y DeGanme:A of Local Garemment Finance
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INSTRUCTIONS: File Mark
To be filed in person or by mail viith the County Auditor of the county whe�e the property is locafed. `�%a,« ,��
Filing Dafes: 1) Real Property: During the 12 months belore May 11 of the year the deduction is to be eflecfive. Q B
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0l the y�af�he�de�n'��b�Yispt�rb�e�ttective.
See reverse side for additional instructions and qual�cations.
Applicant (o er or contract buy - se restricfions on reverse side) '
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Taxing Dislrid Key number / legal description Record number
_ G � L _ � Page number
Assessed value of real property as of Mortgage / ContraC indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, current year March 1, current year owneR 'F.��es ❑ No
7
If no, what is his / her exact share of interesi? If owned with someone other than spouse, indicate with whom.
If name on record is different ihan that of applicant, indicate below: Is the property in question:
eal Property ❑ Mobile Hmie QC 61.1-�
�me of mortgagee or contrad seller
Address of mortgagee or wnt�ad seller mber and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and st�eef, city, state, ZIP code)
Does applipnt own property in any other Ii yes, what county? What Taxing Distrid? Has this deduclion been requested on
county in Indiana? property for wrrent yea(? � Yes � No
COUNTY AUDITOR
Dedudion approved in the amounl of:
20 �z, 20 � 20 �� 20 20 20 20
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Signature County Auditor Date
• We certify under the penalry of perjury lhat the above and foregoing information is true and corred and that lhe applicants was / were
a resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (ownefs (ull name) Person authorized by duly executed Power of Attomey
� � or by IC 6-1.1-12-.07
Full r sident address of applipnt Address of authorized person
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