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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNFcc
FOR DEDUCTION FROM ASSESSED VALUATION
�• �� o' Sute Fortn 43709 (RS / a-03)
� I � PrescribeE by Department of Laal Govemment Finance
INSTRUCTIONS:
To be (+led in person or by mail with the County Auditor of fhe county where the propeRy
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is to (1�ct�c��05
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of th��ar e de uction is to be eflective.
See reverse side for addifional instructions and qualifications. �a� �,/
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Distrid
Assessed value of r�dl properiy
March 1, curtent year
no, what is his / her exact share of interest?
I( name on record is different
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Key number / legal description Record number
db�(� oaa�� Page number
Mortgage / Contrad indebtedness unpaid as of Is the appli�
March 1, curryit year owne(?
that oi applicant, indicate below:
of.mortgagee or contract seller
of moAgagee or contrad seller (number and st�eet, city,
3S?8
[ the sole legal or equitable
❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
Name of assignee or other owner or holder of mortgage
Fddress ot assignee (number and street, city, state, ZIP code)
— -
Does applicant own property Drawer Np, -
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county in Indiana?
Dedudion approved in the ;
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Signature
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3xing Distrid?
Card Np, ,O,S - j S 7�'
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20� 20 20
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County Auditor
> the property in question:
❑ Real Property ❑ Mobile Home QC G1.1-�
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Has this dedudion been requested on
property for current year? � Yes ❑ No
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Date
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We certify undet lhe penalty of perjury that the above and foregoing information is true and corred and that ihe applicants was ! were
resident o( Indiana and owner of the aforementioned property on March 1, 20
�e(owne�s (ull nam Person authorized by duly executed Power of Attomey
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�11E�ddress ofauthonzed person