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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Sfate Fwm 43709 (R4 / 10-07)
PresaibeA by DepaNrenl ot Loral G�vemment Finance
Year
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INSTRUCTIONS: �ile Mark
To be filed in person or by mail with the County Auditor of fhe county where the property is located.
Filing Dates: 1) Real Property: During the 12 months belore May 11 0/ the year the deduction is to be eHective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 31 0/ the year t�ed�lio�toT �effe' tiv
See reverse side /or additional instructions and qualifications.
Appiicant (owner or contract buy - e rgstricUons on reverse ide) ` �
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Taxing 'strid Key number / legal description ecord num �,��v L� 91TOR .
' G166 �.• .�
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/t� O � � /R (�'70 , � � Page number
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As essed value of re operty as of Mortgage / Cantred indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current ye March 1, current year owneR ❑ Yes � No
�aao_�.
Ii no, what is his / her exacl share of interesl? If owned with someone other than spouse, indicate wilh whom.
If name on record is different than thaf of applicant, indicate below: Is the property in question:
❑ Real PropeAy ❑ Mobile Home QC 61.1-�
�me of mortgagee or contrad seller � —
3 q�o
Address of moAgagee or contrad seller (number and stieef, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand st�eet, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for wrrent yeaf? � YesO No
COUNTY AUDITOR
Deduction approved in the amount of:
2o O� 20 97 K 20 20 0!• zo D _ 20 � 20 �
1 � 4 � �
Signature County Auditor Date
�'/ We certify under the penalty of perjury that the above and foregoing infortnation is true and correct and lhal ihe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
' na e(owners (ull n e) Person authorized by duly exewted Power of Attomey
A__ . �' S �, or by IC 6-1.1-12-.07
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ull resident address of applicant Address of authorized person
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