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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Cou � Township� Year
� �«• ! State Form 43709 (RS / a-03) J ` � � �
,� PrescnDed Ey Departmem of Loral Govemment Finance
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INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor o! the county where the propeRy is located. �7ja ,e�
Filing Dafes: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is to be effective. � P
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the yea�-t��t�uchon"isY ���He�'tive.
See reverse side for additional instructions and quali�cations.
Appticant
see
Taxing DisiriG
P�
Assessed value ot real property as of
March 1, wrrent year
Key number / legal description Record numb�
�v-I�.o�-yo3-o433d7-o�8 ,
O/ l- � 3 3a �-� Page number
Mortgage / Contract indebtedness unpaid as of Is the apF
March 1, current year ownef�
If no, whaf is his / her exact snare of interest?
I( name on record is different lhan lhat of applicant,
of mortgagee or contraIX seller
below:
/
��ole legal or equitabie
�s ❑ No
Ii owned with someone other than spouse, indicate with whom.
Address of mortgagee or contract seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
of assignee (number and st2et, city, state, ZIP code)
s the property in questian:
❑ Real Properiy ❑ Mobile Home QC 61.7-�
Does applicant'own property in any other I If yes, what counry? What Taxing District? Has this deduction been requested on
county in Indiana? property for wrrent yea(?� Yes❑ No
approved in the amount
20 n�l I 20
P
Signature
COUNTY AUDITOR
� I 20 �`1 I 20 I 20
P
County Auditor
�
Date
20
We certify under the penalty of peryury that the above and foregoing information is true and correct and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
Signature
Person authorized by duly executed Power of
or by IC 6-1.1-12-.07
resident addre(� of applicant Address of authorized person
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