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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
� �w� ! State Form 43709 (RS / 4-03) �
Prespi�ed by Depanment of Loral Govemment Finance �
iNSrRUCnoNS: PQR 2 12006 F�ie Ma�
To 6e filed in person or by mail wiih fhe County Auditor o/ the county where the propeRy is located.
Filing Dates: 1) Real Property: During the 12 months 6efore.May 11 0l the year the deduction is.to,�e �e���
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ t� y�O tN�rd i{r��s to 6e effective.
See reverse side for additional instructions and qualifications. G�BSON •
Appiicanl (own or contract buyer - see re trictions on reverse side)
Taxing Distrid Key number / legal description Record number �
yN � Jc ��/ / 6 L_ � Page number
YI I 7 �
Assessed value of real property as of MoRgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, currenl year owneR ❑ Yes ❑ No
5 O ��
If no, what is his / her exac[ share of interest? If owned with someone olher than spouse, indicate with whom.
If name on record is difterent than lhat of applicant, indicate below: Is the property in question:
❑ Real PropeAy ❑ Mobile Home (IC 61.1-�
�me of moAgagee or contraq seller _____
Address of mortgage o contrad seller (number and st2et, city, state, ZIP O�_ I 9 p�
Dra��'er NO ...... ..........
Name of assignee or other owner or holder of mortgage —�
CardNO . .....................
Address of assignee (num6er and street, city, state, ZlP code)
Does applicant own property in any olher If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana?
propeAy for current year? � Yes ❑ No
�_ _ COUNTY AUDITOR
Deduction approved in the amount of:
20 .� 20 �' 20 �� 20 20 20 20
� /
Signature County Auditor Date
We certify under the penalty of perjury that the above and foregoing information is true and correct and lhat lhe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full sident address of applicanl Address of authorized person
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