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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' ' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
♦ / Sta[e Fortn 43709 (R4 / 70-0i )
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Prescribe0 by Deparimen� W Lotal Govemment Finance
�INSTRUCTIONS: � � ile a
To 6e filed in person or by mail with the County Auditor of the county where the property is locdted.� JLJ ��
Filing Dates: 1) Real Pmperty: Dwing the 12 months before May 11 0/ the year the deduction is to be effective.
2) Mobile Homes assessed underlC 6-1.1-7: Between January 15 and March 31 o/Bi��ar(t}��d�ion is to be eHective.
See reverse side /or additional instructions and q�alihca6ons.
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Applicant (ownero ntractbuyer-se n'o n rev e e��� "'o`�••v �.vUN7Y AUDITOR �
Taxing Distrid Key number / legal description ecord number � 2
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O/ r!� `O/G � � Page number � �C�
7 / /
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applipnt the sole legal or equitable
March 1, wrrent year March 1, �t year � D� b owner? ❑ Yes ❑ No
I( no, what is his / her exact share of interesl? If owned wifh someone other than spouse, indicate wilh whom.
If name on record is diflerent than that of applicant, indicate below: Is the property in question:
O Real Property ❑ Mobile Home QC 61.1-�
�Name of mortgagee or contrad seller
Address of mortgagee or conVad seller (number and reet, aty, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP code)
Dces applicant own property in any other If yes, what wunty? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for curtent yeaR � Yes 0 No
COUNTY AUDITOR
Deduction approved in the amount of:
zo �_ zo e�/ zo _� io D Zo Q'Z zo �� 20 0
Bv�- /� � � �
Signature County Auditor Date
I/ We certify under the penaity of perjury that the above and foregoing infortnation is true and corred and ihat the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
i ature owners full name) Person authorized by duly executed Power of Attomey
L
- or by IC 6-1.1-12-.07
F esident address of applipnt Address of aulhorized person
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