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� STATEMENT OF MORTGAGE OR CONTF�qCTINDEBTEDNFss
' FOR DEDUCTION FROM ASSESSED j,!ALUATION
� / Sfate Fwm 43709 (RS / 4-03) t
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PreSCribeE by Oepanment of Laal Govemment Fiiurx�
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INSTRUCTIONS: ,_, ----�
To be filed in pers� :_, oy?nail wifh the County Auditor of [he counry where the property
Filing D��;es: tj Real PropeRy: During the 12 months belore May 11 of the year the deduction is to be efleq?ive�1 ��
`� '" : 2) Mobile Homes assessed under IC 6-1.1-7: 8etween January 15 and Maich 2 0/ t��ear the deduction is to 6e eHective.
See reverse side (or additional instructions and qualifrcations. ��
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Applicant (e�vner or contract buyer -
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Taxing
Assessed value of real property as of
March 1, wrrent year
no, w6at is his / her exact share of
on ieverse side)
Key number / legal description
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MoRgage / Contrad ii
March 1, current year
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name on record is different than that of applicant, indicate below:
hme of mortgagee or conlrad seller /1
Address of mortgagee or contraG seller (number and street, city,
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and st2et, city, state, ZIP code)
Does applicant own propeAy in any
county in Indiana?
Deduction approved in the amounl of:
20 �
Signature
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If yes, what county?
Record number
Page number
unpaid as of Is the applicant the sole legal or
owne(? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
ZIP
What Taxing Distrid?
COUNTY AUDITOR
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County Auditor
Is the property in question:
❑ Real Property ❑ Mobile Hane (IC 67.
�-797�
Has this deduclion been requested on
property for wrrent yeaf? � Yes 0 No
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Date
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We certify under the penalty of perjury that the above and foregoing information is true and corred and that lhe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
�n re wner� Iull npme) Person authorized by duly executed Power of Attomey
�( ��� or by IC 6-1.1-12-.07
of authorized person