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°� n�" STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
: FOR DEDUCTION FROM ASSESSED VALUATION Count 7ownship Year
` � State Form 43709 (R3 / 10.00)
Prescribed by Sute Boartl ot Tar Commissioners
Instructions for filing:
To be filed in person or by mail with the County Auditor of the county where Ihe property is
located during the 12 months before May 17 of lhe year the deduction is to be effeclive. See
11 ���a�
NOV 14 2001
reverse side for additional instrudions and qualifiwtions.
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Applicant (owneror ontract buyer- see ieshictions on reverse sid �" " '
Taxing District Key number / le I description Record number Q'
� Ql� r ^ �1� � Page number
d+J
Assessed vatue of real property as of Mortgage /.Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year ownef? ❑ Yes ❑ No
If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
- 9
- e of mortgagee or contrad seller ���'��
Address of mortga e or wntract seller (number 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 applicant own real property in any If yes, whal county? What Taxing Distrid? Has this deduction been requested on
other county in Indiana? property for current year?� Yes❑ No
COUNTY AUDITOR
Dedudion approved in the amount of:
zo p�_ 20 �_ zo � Zo a� _ zo zo QZ zo Q�
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Si ature d �% County Auditor Date
��I'� We certify under the penalry of peryury that the above and foregoing information is true and correct and that the applicants was / were
_�ident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners /ull name) Person authorized by duly executed Power of Attomey
v 1 ��,� ��� �.,�� or by IC 6-1.1-12-.07
Ful esident ad ss oi applicant Address of authorized person
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