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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun" � T;ownshi Year
S J Sfate Form 43709 (RS / 4-03) � � ��, J� g �
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Prescribad by Department of Local Govemment finance
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INSTRUCTIONS: File Maric
To be filed in person or by mail with the CountyAuditor of the county where the property is located. �c� ,CI�
Filing Dates: 1) Real Properry: Dunng the 12 months before May 11 o/the year the deduction is to�be�-effec�ti�e�r�r�.
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year lhe deduchon-Is to:be effective.
See reverse side for additional instructions and qualificafions.
cont2cf buyer- see restr�'ctions on reverse side)
Taxing Distrid -'� � Key number / legal description Record numb
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Assessed value of real property as of Mortgage / ContraG indebtedness unpaid as of Is ihe ap�
March 1, wrrenl year March 1, current year owne(?
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t�F7� sole legal or equitable
rj�-�'es ❑ No
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If no, what is his / her exact share of interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is different than that of applicanl, indicate below: Is e property in question:
I Property ❑ Mobile Home QC 61.
,me of moAgagee or contract seller •
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Address ot mortgagee or contrad seller (numb r and street, city, state, ZIP �
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applipnt own property in any other If yes, what county?
county in Indiana?
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Vuha Card N0. .......57 �O
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COUNTY AUDITOR
)eduction approved in the amount of:
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Signature
County Auditor
20
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Date
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:quested on
❑ Yes� No
certify under the penalty of perjury that ihe above and foregoing information is true and corred and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
name)
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Ful^re"sident addre9� ofapplicant � Address of authorized person