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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R4 / 10-01 j
Coun Township Year
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� Prescribe0 by DePanment ol Locai Govemment Finance �
INSTRUCTIONS: F�iA�ia�:� 2003
To be filed in person or by mail w� y uditor ol the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months 6etore May 11 0/ the year the deduction is to be effec�. � /`�/ n
2) Mobile Homes assessed under IC 61.1-7: Behveen January 15 and Maich 31 0/ the year the.d&�dGctibn+sto"db�eHecd�
�iC 'OtJ CiJU��TY qUp�TOR �
See reverse side for additional instructions and qualifications.
Applicant (owner or contracf buyer - see restrictions on reverse side)
Taxing Distrid Key ber legal descr tion Record number
` Page number
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Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owne(? ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of appficanf, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Hmie (IC 61.1-�
me of moAgagee or contract seller
� Address of mortga ee or wntrad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
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Address of assignee (number and street, city, state, ZIP code) �/
Does applicant own property in any other If yes, what counry? Whal Taxing Distrid? Has this deduction been requested on
counry in Indiana? ;' property for cunent year? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in lhe amount of:
zo 2o zo Q� zo DE 20 0 7 20 �� zo m 9
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Signature County Auditor Dale
We certify under the penalty of perjury that the above and foregoing infortnation is true and corted and thal lhe appiicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners /ull name) Person authorized by duly exewted Power of Attomey
� or by IC 6-1.1-12-.07
F II resident address f applicant Address of authorized person
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