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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�� FOR DEDUCTION FROM ASSESSED VALUATION
I State Fwm 43709 (R5/ a-03)
PresaiDetl by Department of Lotal Govemmeni Finance
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INSTRUCTIONS: � q j �File Mark �
To 6e filed in person or 6y mail with the CountyAuditor olthe county where the property is locate �L g` '��
Filing Dates: 1) Real Property: During the 12 months be%re May 11 of the year the deduction is to be e/ie�f�i�g
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0! the year th2�d��i �o�Qs�t�O be effective.
See reverse side Ior additional instructions and quali�cations. � ,;�% �� /�
(owner or cont�act buyer- see restrictions on reverse side)
(�( _ _ _ a�
Taxing District
Assessed value of real property as of
March 1, wrrenl year
If no, what is his / her exact share of interest?
Key number / legal description
U 1 � ^ LX� 1
MoAgage / Contrect ii
March 1, current year
Record number
Page number
unpaid as of I Is the applicant�sole legal or
owneR es ❑ No
If owned with someone other than spouse, indicate with whom.
If name on record is different than lhal of applicant, indicate betow:
ame of mortgagee or contraIX seller
- � � � S
Address of mortg�e or contract seller (number and street, aty, state, ZIP
Name of assignee or other owner or holder of
of assignee (number and st2et, city,
Does applipnt own property in any other I If yes, what county?
county in Indiana?
approved in the amount of:
20
I
Signature _
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What Taxing i
COUNTY AUDITOR
20 0 to � 20
County Auditor
20 �
Is the property
� Mobile Home (IC 61.
Dra��'er N�• ..................
CardNO• •u•�;•;.`.o��l:•�
�
20
I/ We certiy under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
,resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power oi Attomey
or by IC 6-1.1-12-.07
Full resident address of applic'aht (Address of authorized person