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STATEMENT OF MORTGAGE OR CONTRACT INDE�rFnNFCs
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R5 / 4-03)
� PresrnEM Dy Department of Loral Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the
Filing Dafes: 1J Real Property: Dunng the 72 months before May 11 of the year the deduciion is to,beleffec���3
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of•the yearth eduction is to be eflective.
See reverse side for addifional instructions and qualifications.
Applicant
Tauing Dislrid
Assessed value of real property as of
March 1, wrrent year
If no, what is his / her exact share of interest?
If name on record is
on reverse side)
Key number / legal.description
���/ --C�aZ Pd D ^0 0
ortgage ! Contrad indebtedness unpaid as
arc�gurrent year
thaf of applicant, indicate below:
mortgagee or contrad seller
Record number
Page number
Is the applicant the sole legal or
owneR ❑ Yes 0 No
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If owned with someone other lhan spouse, indicate with whom.
of mortgagee or conVaIX seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
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r�,oaress or assignee �num�---
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COUNTY AUDITOR
Deduction appruvetl in the amounf of:
20
SignaWre
20 ��
20 CJ (O 20 � 20
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County Auditor
s the property in question:
❑ Real Property ❑ Mobile Home (IC E1.1-�
Has this deduction been requested on
property for wrrent yeaR � Yes ❑ No
20 � 20
�
Date
/ We certify under the penalty of perjury lhat the above and foregoing infortnation is true and corred and thal lhe applicants was / were
( residenl of Indiana and owner of the aforementioned property on March 7, 20
address
executed Power of Atlomey
or by IC 6-1.1-12-.07
of aulhorized person