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STATEMENT OF MORTGAGE OR CONTRACT INDI
FOR DEDUCTION FROM ASSESSED VALUATION
State Fam 43�09 (RS / 4-03)
P25cribed by Department of Lecal Govemm?nt Finarwe
vv Coun Township Year
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INSTRUCTIONS: File Maric
To be filed in person or by mail with the County Auditor of the county where the property is Iocat�P�N 1 0 ZQQ6
Filing Oates: 1) Real P�operty: During the 12 months before May 11 of the year the deduction is to be eHective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Belween January 15 and March 2 o%�g�y�� th��uction is to be eRective.
See 2verse side for additional ins6uctions and qualihcations. ��/ '�s
OIB80N COUNTY AUDITOR
Appli nt (ownerorp�nt uyer- see restrictio s on reverse sid ) '
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Taxi Dislri Key number / leg description Record number O�
W�\ I�- a y g s cx� Page number � �
Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owneR ❑ Yes ❑ No
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I( no, whaf is his / her exacl share of interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is dif(erent than that of applicant, indicate below: Is the property in queslion:
❑ Real PropeAy ❑ Mobile Home (IC 61.1-�
�me of moAgagee ar contrad seller �
Address of moRgagee or cont�ad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Districl? Has this deduclion been requested on
couny in Indiana? property for curcent yea(? � Yes � No
COUNTY AUDITOR
DeducGon approved in the amount of:
20 O7 20�'� 20 Oq 20 20 20 20
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Signature County Auditor Date
We certiTy under the penalty of perjury lhat the above and toregoing infortnation is true and corred and that ihe applicants was / were
resident of Indiana and owner of lhe aforementioned property on March 1, 20
Sig tur wners full name) Person authorized by duly exewted Power of Attomey
or by IC 6-1.1-12-.07
F ent dress of p nt Address of authorized person
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