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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fofm 43709 (R4 / 10-0i)
PrescribeA by Departmen� W Local Govemment Finaxe
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INSTRUCTIONS: � ile Ma
To be filed in person or by maii with the County Auditor of the county wheie the property is located.
Filing Dates: 1) Real Propedy: Dunng the 12 montbs 6elore May 11 0l the year the deduction i�5.to<be e�e.� nR
2) Mo6ile Homes assessed under IC 61.1-7: Between January 15 and March 31 0/ the`year fhe deduction is to be eliective.
See reverse side for additional instiuctions and qualifica6ons.
Applicant (owner or cont t b er- e stric6ons on revers id
Taxin Dis ' Key number / legal descripti Record number _
/ _ � _ � Page number
Assessed vatue of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applipnt the sole legal or equitable
March 1, current year March 1, current year owne(? �❑ No
/ l./�/L/
Ii no, what is his / her exacl 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: Is the property in question:
�eal Property ❑ Mod7e Home (IC G1.1-�
Name of mortgagee or contract seller
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Address of mortgagee or conVad seller (number and sf2ef, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and stieet, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this deduclion been requested on
county in Indiana? property for wrrent year? 0 Yes 0 No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �,�_ 20 20 �`� 20 � 20 � 20 $ 20 �_
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Signature CouMy Auditor Dale
I/ We certify under the penalty of perjury that the above and foregoing infortnation is true and correct and lhat the applicants was / were
cesidenl of Indiana and owner of the aforementioned property on March 1, 20
� ignature owners lull name) � Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
uil esident address of applicant Address of aulhorized person
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