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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Sfate Fortn 43709 (R6 / 5-06) �
Presrnbed by Department of Lonl Gwemment Finance
INSrRUCTIONS:
To be /iled in pe�son o� by mail with the County Audito� 07 the county whe�e fhe prope�ty is located. 'II
Filing Dates: 1) Real Property: Dunng the 12 months before June 17 of the year the deduction is to be�H�cti�e.9 2�0%
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the ye r the deduction is to be effective.
See reverse side /or additional instructions and quali�cations. �� ��
���.�vrv �;VUNTY qUDITOR
Applicant (ownerorco ct er- s e restricti ns rev e si e
Taxing DistriIX Key number / legal description Record number D
Q O�10 —b Y�D`� ����. to �0 � number O� /(o �
Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, current year owneR ' ❑ Yes ❑ No '
��Ga� ,
If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicanl, indicate below: Is the property in question:
❑ Real Properiy ❑ Mobile Hmie (IC E1.1-�
�me of mortgagee or contract seller ��J
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Address of moAgagee or contract seller (number and stieet, city, state, Z :- r:-
Name of assignee or olher owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicanf own property in any other If yes, what county? What Taxing Distric[? Has this dedudion been requested on
county in Indiana? property for curtent year? (� Yes � No
� COUNTY AUDITOR
Dedudion approved in the amounl of:
20 Q� 20 �� , 20 20 20 20 20
P P
Signature County Auditor Date
� We certify under lhe penalty of perjury that the above and foregoing informalion is true and correct and that lhe applicants was / were
�sident.of Indiana and owner of the aforemenlioned property on March 1, 20
Signature (owne/s full name) Person authorized by duly executed Power of Attomey
or by IC 6-t.t-12-.07 '�
Full resident address of applicant Address of authorized person