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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (RS I 4-03)
PresaiDeO by Department ot Local Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with ihe County Auditor of the county whe2 the property is located. AP R 2 20�4
Filing Dates: f) Real Property: Dunng the 12 months be%2 May 11 0/ the year the deducfion is to be eRective.
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the y' �/a'r the deduUion'is to be /e/ffec� e.
See reverse side /or additional instnictions and quali�cations. /,ru„�,i.�i y J�c...J4.:��
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Applicant
on reve�se side)
Taxing District �� Key number / legal description Record number
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Assessed value of real property as of Mortgage / Contrect indebtedness unpaid as of Is the applicant the sole legal or eq
March 1, current year March 1, current y�a� ownef? ❑ Yes ❑ No
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 the property in question:
❑ Reai Property ❑ Mobile Home QC 6-1.1
�ame of moAgagee or contract selier _
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Address of mortgagee or conlrad seller (number and street, city, stafe, ZIP
Name of
Address
or other owner or holder oi mortgage
(num6erand s6eet, city, slate, ZIP
Does appliqnt own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for wrrent yeaR � Yes❑ No
Deduction
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in the amount of:
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COUNTY AUDITOR
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County Auditor
Drawer NO. a��..'.:.... '
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Card NO.�.�Q% �•�� ••
/ We certiry under the penalty of perjury that the above and foregoing informalion is true and corred and that the applicants was / were
I resident of Indiana and owner of the aforementioned property on March 1, 20
(owners full name)
applicant
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Person authorized by duly executed Power of
or by IC 6-1.1-12-.07
Address of authorized person