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�e, � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�s : FOR DEDUCTION FROM ASSESSED VALUATION �� Year
'� SUte Form 43709 (R6 / 546) � . .
� Prespibed by Depanment o` Loral Govemment Finance � . �
INSTRUCTIONS: � � �Fi,IQ Mark
To be filed in person or by mail with the County Audito� o/ the county where the p�operty is located. �' �
Filing Dates: 1J Real Property: Dunng the 12 months before June Il of the year�the deducGon i��g�ft��TY A piTo R
� 2J Mobile.Homes assessed under IC 61.1-7: Between January 15 and March 2 0( the year the deducGon �s [o be eHective.
See �everse side (or additional instn�ctions and qualifrcations.
Applica t(owner or contract buyer- see restnctions on reverse side)
Tazin Distrid Key number gal description Record number
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o?�O"/a D %" �(/ �'O � � Page number �'$ / /
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Assessed value of real property as of Mortgage / Contred indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, currenl year March 1, wrtent year ownefJ ❑ Yes ❑ No
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If no, whal is his / her exact share of interesl? If owned with someone other than spouse, indicate with whom.
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If name on record is different ihan that of applicant, indi�te below: n li' Is he property in questio�
t�,,.._ � l,ll r� '--CI R� �-- I.t-�
�me of mortgagee or contrad seller - �y
Address ot moRgagee or conVaIX seller (num r and street, city, state, ZIP Dra" er
Np...�'� .. ...
.. .. �4�+ �*''.......
Name of assignee or other owner or holder of mortgage C3T(1 ��' " �p ��
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Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has lhis deduction been requested on
county in Indiana? praperty for wrcent yeaf? � Yes � No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �`� 20 �_ 20 20 20 20 20
f �
Signature County Auditor Date
� We certify under the penalty of perjury thai the above and foregoing information is true and corred and that the applicants was / were
. residenl of Indiana and owner of the aforementioned property on March 1, 20
Sign re (o e/s (ull name) Person authorized by duly exewted Power of Attomey
��J � or by IC 6-1.1-12-.07
Fu resident address of applicant � Address of authorized person
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