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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Cqoun 7ownship Year
Sure Form 43709 (RS / a-03) �1 �
PrescnEed Oy Department ot Loral Govemment Finance - l
INSTRUCTIONS:� OCr O � 20��e Maric
To be filed in person or by mail wifh the County Audiror ot the county where the property is located� �
Filing Dates: 1) Real PropeRy: Dunng the 12 months before May 11 0/ the year the deduction is to be�e/%ctlY � �
2}Mobile Homes assessed under IC 6-1.1-7: Between January 15 and MarchQ�aGYb��ea��Ty edu'ction is to be eBective.
See 2verse-side for additional insfructions and qualifications. AUDITOR
nppucant (owny{orcontrac( buyer-
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Taxing Distrid
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Assessed value oi real property as of
March 1, current year
on reverse side)
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Key number / legal description Record number ./
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Q/ �_ �O /O— � Page number � �� �
MoRgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owner? ❑ Yes ❑ No
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I( nq v�hat is his / her exact share of interest? If o�
If name on record is different than that of applicant, indicate below: _
of mortgagee or contract seller
Address of mortgagee or contract seller (number and
Name of assignee or other owner or
Address of assignee (number and street,
Does appliwnt own property in any other
county in Indiana?
Deduction approved in lhe amount of:
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Signature
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of mortgage
ty, state, ZIP code)
�, yes, what county?
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sfate, ZIP
with someone other than spouse, indicate with whom.
What Taxing Distrid?
s the property
❑ Real Property ❑ Modle Home QC 61.1-�
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Dra�ver i\'0.�........... -
Card i�'O. . �D5,3�i
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County Auditor
Has this deduction been requested on
property for current yeaR � Yes 0 No
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Date
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' We certify under the penalty of perjury that the above and foregoing information is true and correct and lhal the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
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address of
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person