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ii� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�s FOR DEDUCTION FROM ASSESSED VALUATION Count Township Year
� ! State Form 43709 (R6 / 5-06) �
� Presvibed by Departr.!ent of Lorvl Gwemment Finarite ^ i 1\
a°
INSTRUCTIONS: �� � File Mark
To 6e filed in person or by mail with fhe CountyAuditor of the county where the property is located.
Filing Dates: 1) Real P�operty: Dunng the 12 months before ,lune f 1 0/ the year the deduction is to be e(/ective.
2J Mobile Homes assessed unde� lC 6-1.1-7: Between January 75 and March 2 0/ the year the deduction is to be elfective.
See reverse srde for additional instructions and qualifications.
Applicant(o rorcontractbuyer
Taxing d
.� � .
pn feverse side)
Key number / legal description Record number
�� �a� �ioa �vi i�ro
Page number
�
Assessed value of real property as of Mortgage / ContraC indebtedness unpaid as of Is the;applicant t e sole legal or equitable
March 1, current year March 1, wrrent year owne(? ❑ Yes � No "
O� �
If no, what is his / her exact share of interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is different ihan that of applicant, indicate below:
�me of mortgagee or contract seller I -�/�
Address of mortgagee or contrad seller (number and st et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee
Does applicant own property in any
county in Indiana?
street, city, state, ZIP code)
Deduction approved in ihe amounl of:
property
❑ Real Property ❑ Mobile Hmie (IC 61.1-�
If yes, what county? What Taxing �I/Y`�S _?���
d(N / J
c/��
�r�i���i�m
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Signature
COUNTY AUDITOR • �
�
County Auditor
20 ��� �OO�.s�.�a T
�r �
Date
iesrea on
Yes 0 No
We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
nat re (owners full name) Person authorized by duly executed Power of Attomey
i
r e..� _. _�'; ,�_ i Li� or by IC 6-1.1-12-.07
of autho�zed person