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i� � STATEMENT OF MORTGAGE OR CONTRACT INDEB�D �
= FOR DEDUCTION FROM ASSESSED VALUATION C u Township Year
'e�.,. . � State Fwm 43709 (R6 / 5-06)
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� Presoibed by Department of Lwal Gwemment Finance
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INSTRUCTIONS: �lj� � File Mark
To be filed in person or 6y mail with the County Auditor ol the county where the�r�p��' is l6Eated�
Filing Dates: i) Real Property: Dunng lhe 12 months 6e(ore June 11 of the year the deCr%�iilN�'to,Qg�p�ive.
2J Mobile Homes assessed unde� IC 6-1.1-7: Between January 15 and March 2 o(the year the deduc6on is to be eltective.
See reverse side for additional instructions and qualircations.
Appticant (owner or contra uyer- see restndions on reverse side) -
Taxing Distrid Key number / ega scnption Record nu r
, � h � O � � number
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole gal or equitable
March i, current year March 1, current year ownerl ❑ Yes ❑ No
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If no, what is his / her exad share of interest? If owned with someane other lhan spouse, indicate with whom.
If name an record is difFerent ihan that of applicant, indicate below: Is the property in question:
❑ Real Properiy ❑ M�ile Home (IC 61.1-�
me of moRgagee or contrad selier
Address of mortgagee or conVad seller (number an treet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, sfete, ZIP trode) __
Dces applicant own property in any oth ;�? Has lhis dedudion been requested on
county in Indiana? Q �. �.� � I property for curcent yeaf? � Yes ❑ No
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Dedudion approved in the amounf of:
20 �_ 20 �� 20 20 20 20 20
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Signature Counry Auditor Dale
1/ We certify under the penalty of perjury that the above and foregoing infortnation is true and corred and lhat the applicants was / were
sident of Indiana and owner of the aforementioned property on March 1, 20
�nature owners full name) r Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
I esident address of appl�pnt Address of authorized person
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