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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (RS / 4-03)
Presai0e0 by Departmeni ot Loral Govemment Finance
INSTRUCTIONS:
To 6e filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months belore May 11 0/ the year the deduction is to 6e eflective. �� r 4 q�n�
2) Mobile Homes assessed under IC 6• 1.1-7: Between January 15 and March 2 0l the year the deduction �s �o be efl� !fJ€
See reverse side for additronal instructions and qualifications. ,/ � (;
Applicant (owner or
Taxing District
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Assessed value of real property as of
March 1, curtent year
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� � ns on re�
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no, what is his / her exact share of interest?
number I iegal description
number O 3 _ /O a3 �
Page number
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Mortgage / Contract indebtedness unpaid as of Is the applicant the ole legal or equitable
March 1, wrrent year owner? �s ❑ No
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If owned with someone other than spouse, indicate with whom.
name on record is different than that of applicant, indicate below:
of mortgagee or contract seller
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ss of mortgagee or contrect seller (number and street, city, state, ZIP
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 I If yes, what couniy? I What Taxing
wunty in Indiana?
COUNTY AUDITOR
Deduction approved in the amount
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Counry Auditor
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Is the property in question:
Ij}�Real Property ❑ Moble Home (IC E1.1-7)
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CJ�-lD,�o
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`� � ;ted on
5 ,,: :SoNo
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20 � 20
Date �
We certify under the penalty of perjury that the above and foregoing infortnation is true and correct and that the applicants was / were
�sident of Indiana and owner of the aforemeniioned property on March 1, 20
Person authorized by duly executed Power of Attomey
ar by IC 6-1.1-12-.07
Address of authorized person