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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
i�♦ Stata Fortn 43709 (R5 / 4-03) . �
� Prescribetl by Department of Loral Guvemment Finance
INSTRUCTIONS:
Coun Township Year
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� `—`File Mark --�
To 6e filed in person or by mail with the County Auditor of the county where the property is located. FEB 2 6 2004
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to be effect�ve.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is to be e/%ctive.
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See reverse side for additional instructions and qualifications. I//
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Applicant (ow or co tract 6uyer - see s'ctions on reverse ' e)
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Taxin strid Key number / legal description Record number
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Assessed value of real property as of Mortgage / ContraU indebtedness unpaid as of Is the applicant lhe so e legal or equitable
March 1, curcent year March 1, current year owner? ❑ Yes ❑ No
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If no, what is his / her exad share of interest? Ii owned with someone other than spouse, indicate with whom.
If name on record is different ihan Ihaf of applicant, indicate below: Is lhe property in question:
❑ Real Property O Mobile Home QC G1.1-�
�.me of mortgagee or contrad seller
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Address of mortgagee or contract seller (number sf t ity tate, ZIP (3
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Name of assignee or olher owner or holder of mortgage
Address of assignee (num6erand s6eet, city, state, ZIP code)
Does applicant own property in any other If yes, what counry? What Taxing District? Has this dedudion been requested on
county in Indiana? property for current yeaf?� Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
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Signature Counry Auditor Date
We rtiy under the penalty of perjury that lhe above and foregoing infortnation is true and corred and that the applicants was / were
res' ent of Indiana and owner of the aforementioned property on March 1, 20
i at e(owne(s /ull name Person authorized by duly executed Power of Attomey
' � or by IC 6-1.1-12-.07
F resident addre of a' nt � Address of aulhorized person
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