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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709 (RS / 4-03)
Presai�ed by Departmenl of L�xal Govemment Finance
INSTRUCTIONS: � �( � �j� , �y,(�a�
To be filed in person or by mail v✓ith the Counry Auditor of the county where the property is l�oc�ate�d� �U�
Filing Dates: 1J Rea/ Property: Dunng [he 12 months 6efore May 11 oI the year the deduction is to be e8ective,inn5
2) Mo6ile Homes assessed under IC 6-1.1-7: Behveen January 15 and March 2 of theCyvar tl�e deducbon is to be eHective.
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A plica (owner or conhact buyer- see ions on reve e side G18SON �pUN `'
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Taxmg Districl Key number / legal description Record number ��^�
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Q�Q - OU �i� -� Page number I.0 �
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owne(? ❑ Yes ❑ No
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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 difierent ihan that of applicant, indicate below: Is the property in question:
Property ❑ Mobile Hane QC Cr1.1-�
�e of mortgagee or contraIX seller
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Address ot mortgagee or contract seller (number an t2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
counly in Indiana? property for current yeaf? � Yes� No
COUNTY AUOITOR �
Deduction approved in the amount of:
20 20 �_ 20 �_ 20 20 20 20
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Signature County Auditor Date
We certify under the penalty of perjury that the above and foregoing infortnation is true and correcl and that the applicants was / were
resi t of Indiana and owner of the aforementioned property on March 1, 20
Sign tur ( wners full name / Person authorized by duty executed Power of Attomey
/� ��/}� or by IC 6-1.1-12-.07
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esident dress of applicant Address of aulhorized person
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