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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION ,.
S�ate Form 43709 (R6 / 5-0G)
Presaibed by Depariment of L«al Govemment Finance
INSTRUCTIONS:
To 6e filed in person or by mail with the County Auditor of the county whe�e the p�operty is locaieu. �- -�--• • �� �
Filing Dates: 1J Rea/ Property: Dunng the 12�months befo� dune Il of the year the deduction is to be eSective.
2) Mo6ile Homes assessed under IC 6-1 J-7: �Between January 15 and March 2 of the year the deductlon is to be eHective.
See reverse side for additional instructions and qualifications.
Applicant (o er or contract 6 r- see
Record number /'
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� h - � �. �a �- 6 � Page number �
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AssessEd value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owneR ❑ Yes '� No "
O � C�I.LJ . .
If no, what is his / her exad share of interest? If owned wifh someone other than spouse; indicale with whom.
If name on record is different than ihat of applicanf, indicate below: is the property in question: ,
D Real Property ❑ Mobile Home (IC Cr1.1-�
�e of mortgagee or contrad seller
Addreas af mortgagee or contract seller (number and st2et, city, state, ZIP
Name ot 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 If yes, what county? Q / n requested on
Dra«�er ' .....
countyinlndiana? ��•.. ,,,�O,Y�/ 3(��Yes❑No
Card NO . .....................
COUNTY
Deduction approved in the amount of:
20 0 Y 20 � 20 20 20 20 20
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Signature County Audilor Date
We ceAify under lhe penalty of perjury that the above and foregoing information is true and corred and thal ihe applicants was / were
. residenl of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners (ull name) Person authorized by duly executed Power of Attomey
�� � or by IC 6-1.1-12-.07
� Ful resident address of applicant Address of authorized person
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