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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
1� / SUte Form 43709 (RS / 4-03)
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PrasaibeE Dy Department ot Local Govemment Finance
�RUCTIONS:
To 6e filed in person or by mail with the County Auditor o) the county where the property is located. 2003
Filing Dates: 1) Real Property: Dunng fhe 12 months before May 11 0/ the year the deduction is to be effectiveN � � 3
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction is to be effect� e.
See reverse side for additional inshuctions and qualifications.
�SO��� � FUGIiOR
Applicant (owner or cont er - see restrictions on rse si �
Taxing District Key nu r/ leg I escription Record number Q�
�� �O Q D n n� '� Page number I^ r
l (J/ 'IJ
Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole tegal or equitable
March 1, cunent year March 1, current year owner? ❑ Yes ❑ No
1 Q O 6�'p
If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is diHerent lhan that of applicant, indicate below: Is the property in queslion:
❑ Real Property ❑ Mobile Home (IC E1.1-7)
re of mortgagee or contrect seller �
ress of mortgagee or contract seller (number and street, cily, state, 21P
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, ciry, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduction been requesied on
county in Indiana? property for current year? ❑ Yes❑ No
COUNTY AUDITOR
Deduction approved in the amouni of:
20 20 � 20 20 �� 20 20 �� 20
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Signature County Auditor Date
�/ We certify under the penalry of perjury that the above and foregoing infortnation is true and correct and that the applicants was I were
resid t of Indiana and owner of the aforementioned property on March t, 20
ure (owne full n e Person authorized by duly executed Power of Attorney
` or by IC 6-1.1-12-.07
ull sident address ap can ' ddress of authorized person
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