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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�'. �N� ! State Fortn 43709 (R514-03)
� PresaiCetl Dy Department of Local Govemment Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail wfth the County Auditor of the county where the propeRy is located. -
Filing Dates: 1) Real Property: During lhe 12 months before May if o/the year the deduction is to be effective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction is to be effective.
See reverse side 1or additional instructions and qualifications.
Applicant (owner or contract buyer
Taxing Distrid
on reverse
Key number / legal desaiption
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:� �� I'
number
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Q � � '..�i �1�; Page`numb'ei'! � �
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Assessed value of real property as of MoRgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrtent year March 1, current year ownef? ❑ Yes ❑ No
If no, what is his / her exacl share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
�re of mortgagee or contract seller �
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Address of mortgagee or contract seller (number and sfreet, city, state, ZIP
Name of assignee or other owner or holder of moAgage
Address of assignee (numberand sVeet, city, state, ZIP code)
Does applicant own property in any ofher If yes, what county? What Tazing Distrid?
county in Indiana?
Deduction approved in the amount of:
20
Signature
20
�
COUNTY AUDITOR
20 � 20 � 20
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County Auditor
; the property in questian:
❑ Real Property ❑ Mobile Home pC 61.
Has this deduclion been requested on
property for current year? � Yes 0 No
20
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certify under the penalty of perjury lhat the above and foregoing information is lrue and correct and that lhe applicants was l were
ienl of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duty executed Power of Attorney
or by IC 6-1.1-12-.07
oi authorized person