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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNFSS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (RS / 4-03) - •
P2scriDed by Department of Loral Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor ol the county where the property
Filing Oates: 1) Real Property: Dunng the 12 months be(ore May 11 0l the year the deduction is t /fgct�v�006
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ th ear fhe deduction is to be eNective.
See reverse side (or additional inshuctions and qualiTcations. ,�i6� ,�d�,
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NTY AUDITOR
Applicant (owner o�ract buyer- see restri 'ons on reverse side)
Taxing Distrid Key number legal descri Record number
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Assessed value oi real property as of MoAgage ! Contrad indebtedness unpaid as of Is the applicant the sole legal or equitabte
March t, cunent year March 7, current year owneR �'es ❑ No
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If no, what is his / her exact share of interesl? I( owned with someone other lhan ouse�yindicate with��y hom.
a�/- .35�0Y
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If name on record is different than that of applicant, indicate below: Is �e�Operiy in question:
O I PmpeAy ❑ Mobile Home (IC 61.1-�
�me of mortgagee or contraU seller �
Address of mortgagee or contreIX seller (number and street, city, state, IP '
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this dedudion been requested on
county in Indiana? property for current year?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 Q� 20 �_ 20 Q� 20 20 20 20
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Signature County Auditor Date
•We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners full name) Person authorized by duly executed Power of Attorney
�� � or by IC 6-1.1-12-.07
ull resident addr ss of a lipnt ,^� Address of authorized person
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