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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES�
FOR DEDUCTION FROM ASSESSED VALUATION
S M/ State Fortn 43709 (R5/ 4-03) . _
� PrescnDed by Department of �ocal Govemment Financa
INSTRUCTIONS:
To be filed in person or 6y mail with the County Auditor of the county where the property is
Filing Dates: 1) Real Property: During the 12 months before May 11 of fhe year the deduction is to b�e�ecti�! LUUY
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year [he dedu/c{t,ion is
See �everse side for additional instnictions and qual�cations. %� ,�, 7;. , N
Applicant (owner
see restr
"� IlX
Assessed value of real property as of
March t, current year
If no, what is his / her exad
on
Key number / legal description Record number p� �/
(J `>"
a( /�_ O/�aQ rQ� Page number �� /7
��
Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1�rrent year owneR ❑ Yes ❑ No
�oo �
If owned with someone ofher lhan spouse, indicate with whom.
If name on record is different than that of applicanl,
�ame of mortgagee or contrad seller ��
Address of mortgagee or contract seller (number and st2et, city,
Name of assignee or other owner or holder of morigage
Address of assignee (number and st�eet, city, state, ZIP
Does applicant own property in any other I If yes, what counry? What Taxing Distrid?
county in �ndiana?
Deduction approved in the amount of:
20 O y= � 20 �� � 20
0
COUNTY AUDITOR '
s the property in question:
❑ Real PropeAy ❑ Mobile Home (IC &1.1-�
�. ;�' ,
`r .
Has this deduction been requested on
property for wrrenl yeaf� 0 Yes � No
' SµAu� '7�;�CtS� �.
� LEw�s
County F
20
b�-3���
/ We certity under the penalty of perjury that the above an it the applicants was / were
� resident of Indiana and owner of the aforementioned pro{,�„y „�� �.,o�u� �, ��
gnat re (owners /ull name Person authorized by duly executed Power of Ariomey
'J����� ��� or by IC 6-1.1-12-.07 .
asitlent atltlress of applicant Address of authorized person
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