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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
" FOR DEDUCTION FROM ASSESSED VALUATION
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/ Sute Fom: 43709 (RS / 4-03) . . '
� Prescdbed by Depanmeni of Local Gdvemment Finance ' �
INSTRUCTIONS:
To be filed in person or by mail with the CountyAuditor of the county where the property is loc_.__.
Filing Dates: 1) Real PiopeRy: During, the 12 months 6elore May 11 o/the year the deduction is to be eflectiv�AY 1 1 Z��6
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is to be effective.
See reverse side for additional instnictions and qualifications. �-�,.,�� ��
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Applicant (owner or
Taxing
Key number / legal description Record number O'
/ Q Q�� Q O�6 2. Q Q Page number �
Assessed value of real p rty as of Mortgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1; current year March 1, current year owneR ❑ Yes ❑ No
QO �
If no, whal is his / her exact share of interest? Ii owned with someone other than spouse, indicate wilh whom.
I( name on record is diHereni than that of appticant, indicate below: Is the property in question:
_ _ ❑ Real Pmperty ❑ Mobile Home (IC 6-1.1-�
,me of mortgagee or contract seiler �/�
Address o( mortgagee or contred seller (number and streef, city, state, ZIP
Name of assignee or other owner or holder of mortgage
(number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Dislrict?
county in Indiana?
20
Signature
approved in lhe amount of:
r� � -
COUNTY AUDITOR
20 � 20 20
�
County Auditor
Has this dedudion been requested on
property for wrrent year? � Yes� No
20
Date
20
Ve certify under the penalty of perjury that the above and foregoing in(ormation is true and corred and that the applicants was / were
�.sideni of Indiana and owner of the aforementioned property on March 1, 20
atyre (owners full name) Person authonzed by duty executed Power of Attorney
�� ���� or by IC 6-1.1-12-.07
resident address of applicant Address of aulhorized person
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