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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS �
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S / State Fwm 43709 (RS / 4-03) ��
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� PrescnDed Ey Department ot Local Govemment Finance /
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INSTRUCTIONS: � File Mark
To be filed in person or by mail wfth the County Auditor of the county where the property is located.
Filing Dates: 1J Real Property: During the 12 months be/ore May 11 0/ the year the deduction is to be eflective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is to be eHective.
See reverse side (or additional instructions and qualifications.
Applicant (owner contract buyer- s e restnct s on reverse side)
Taxing Dislrict I Key number / legal desuiption Record number
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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, curcent year March 1, current year ownef? ❑ Yes ❑ No
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If no, what is his / her exad share of interest? If owned wifh someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real Properiy ❑ Mobile Hane pC 6�1.1-�
�me of mortgagee or contract seller /�� ��
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Address of mortgagee or conlract seller (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6erand street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this dedudion been requested on
couniy in Indiana? ' property for currenl yeaf? Q Yes � No
COUNTY AUDITOR
Deduction approved in the amount of:
zo1Q� zo B•� 2o zo� Drawer NO ................... I—
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Card NO. .�...��..:.�5.�� C
ignature County Auditor
�' I We certify under the penalty of perjury that the above and foregoir.� ...._...._.._..._ ....................... �,... ,.�o..��� o�N��,.a���� was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
� Signa owners fu e) Person authorized by duty executed Power of Attomey
�� or by IC 6-1.1-12-.07
F II resi ent dress of a plicant Address of authorized person
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