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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
Stata Fwm 43709 (R4 / 1401)
PrescnDetl Dy Deparimen� W Local Govemment Finaixz T ., ��
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INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor of the county whe�e the property is l�ted.`! 3 Z�03
Filing Dates: 1) Real Pioperty: During the 12 months 6e%ie May 11 of the year the deduction is to be e/fective.
2) Mobile Homes assessed under IC 61.1-7: Between January 15 and March 31 0/ the year the deductio"n is to be eflective.
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See reverse side for additional insfiictions and qualificaGons. �-���% +J7 "- '-" '� �
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Applicant (owner or contra buy r- see 2stn s o r verse side)
Taxing Distri Key number / legal description Record number ��
�il�/(/C�, �� (p —�7 7S—c.�/ Pagenumber %.3 ��'
Assessed value of real property a of MoAgage / Contrad indebtedness unpaid as of Is lhe applipnt the sole legal or equilable
March 1, curtent year March�curtent year owne� ❑ Yes ❑ No
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If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate wilh whom.
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If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real Pioperty � Mobile Hmie (IC 61.1-�
�ame of mortgagee or contrad seiler
Address of mortgagee or conUact seller (number an sheet, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has lhis dedudion been requested on
county in Indiana? property for cunent yeaR O Yes O No
COUNTY AUDITOR
Deduction approved in the amount of:
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Signature County Audilor Date
�1/ We certify under lhe penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
resident of Indiana and owner of the aforemenlioned property on March 1, 20
S'�ture (owner' ll n me Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full ident ad e of applicant Address of authorized person
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