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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
♦ � / Stata Fwm 43709 (RS / 4-03)
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� PrescriDetl Cy Department of Laal Govemment Finance
INSTRUCTIONS:
To 6e filed in person or by mail with the County Auditor ol the county where the property is lo
Filing Dates: 1) Real Properry: During the 12 months befo�e May 11 of the year the deductior
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2
See reverse side for additional instructions and qualifrcations.
Applicant (owne orcon t r- sp�e restrictions on reve e ide)
Taxing Distrid Key number / legal description Record number
I.���{... ^C�/, �) y _ �����M Pagenumber
U �W'' Q tiC.J
Assessed value of real property as of Mortgage ! Contrad indebtedness unpaid as of Is the applipnt the sole legal or equitable
March 1, current year March 1, currenl year ownef? ❑ Yes ❑ No
If no, what is his / her exact share of interesl? If owned with someone other than spouse, indicate with whom.
If name on record is different lhan that of applicant, indicate below: is the property in question:
❑ Real Property ❑ Mobile Home (IC 61_t-�
�me of mortgagee or contract seller �
Address of mortgagee or contrad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, sfate, ZIP code)
Does appticant own property in any other If yes, what county? What Taxing Distrid? Has this deduclion been requested on
county in Indiana? property for current year? �] Yes � No
COUNTY AUDITOR
Deduction approved in the amounf of:
20 O 20 20 20 � 20 �� 20 20
PYRrbo+@' � P P P
Signalure County Auditor Date
�'/ We rtify under the penalty of pe�jury that the above and foregoing informalion is irue and corred and fhat the applicants was / were
r ident of Indiana and owner of the aforementioned propeRy on March t, 20
' ature (owne �s /ull name) Person authorized by duly executed Power of Attomey
«`� � or by IC 6-1.1-12-.07
ull siden address f applicant Address of authorized person
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