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a`° R�" � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
`'� '_ = FOR DEDUCTION FROM ASSESSED VALUATION P
Count Townshi Year
S�/ SUte Form 43709 (Ra / 10-07)
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� Prescribe0 by Depariment of Local Govemment Finance
INSTRUCTIONS: � � � �e ark
To be filed in person or by mail with the County Auditor o/ lhe counly whe2 the propeRy is loc e
Filing Dafes: 1 J Real Property: During the 12 months belore May 11 0/ the year the deduction o be ef/ective.
2) Mobile Homes assessed under IC 6-1.1-7: Behveen January 15 and March 31 0/ the ��th� d�d�� is to be e/%ctive.
See reverse side (or additional instructions and qualifications. �, _
Applicant (ownerorcontract b yer- see restrictions on
Taxing istrid -�y Key un
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of real property as of
March 1, wrrent year
If no, what is his / her exact share of interest?
legal description � — � Record number
number
Mortgage / Contract indebtedness unpaid as of Is the applicant the sdle legal or
March 1, current year j/ �� � owner? ❑ Yes ❑ No
.-�ce .i(�%S%�� �a J
If name on record is diftereni ihan that of applicanl, indicate below:
of mortgagee or coniraIX selier
Address of moAgagee or contrad
Name of assignee or
Address
owner or
(numbe� and street, city, state, ZIP code)
Does applicant own property in any olher I If yes, what counry?
county in Indiana?
Deduction
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the amounl of:
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If owned with someone olher than spouse, indicate with whom.
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What Taxing Distrid?
COUNTY AUDITOR
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09 County Auditar
s the property in question:
❑ Real Property ❑ Mobile Home QC 61.1-�
Has lhis deduclion been requested on
property for current year? � Yes ❑ No
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Date
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certify under the penalry of perjury that the above and toregoing information is true and correct and that the applicants was / were
leni of Indiana and owner of the aforementioned property on March 7, 20
ire (owners (ull name)
,��y/�'
cident address of aoolica
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
of authorized person