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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
S�ate Fofm 43709 (R4 / 1601)
Prcuribed by Deparimenl oi Locat Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor o( the county where the property is located. � � � 1(j z��3
Filing Dates: 1 J Real Property: During the 12 months before May 11 0/ the year the deduction is to be e/fective.
2) Mo6ile Homes assessed under IC Gl. f-7: Between January 15 and March 31 0( the'"year the deductiori is to be eflective.
See reverse side for additional instructions and qualifrcations. A�,�J _^�
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Applica owner o contracf buy - see 2 tri 'ons o reverse side)
Taxing Distrid Key number / legal descriplion Record number �� Z
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�,E / D /�. , �//� O��/.��� Pagenumber ��\
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrrent year March 1, curtent year O� owne(? ❑ Yes ❑ No
c/�d Q/�
I( 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 applicanl, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-�
�me of moRgagee or contract seller ,
Address of mortgagee or conVact seller (number and st e ciry, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
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Does applipnt own property in any other If yes, what county? What Taxing District? .�'' � 07 � sted on
county in Indiana? es� No
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COUNTY AUDITOR
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Deduction approved in lhe amount of:
20 20 .p� 20 �(� 20 O r/ 20 � 20 � 20
f / ti /
Signature County AudRor Date
'/ We certify under the penalty of perjury lhat the above and foregoing informalion is true and corred and that the applicants was / were
�resident of Indiana and owner of the aforementioned property on March 1, 20
Sigpature (owners /ull name) � ,�,/� Person authorized by duly executed Power of Attomey
�, � L. ( Il i� r n 1 or by IC 6-1.1-12-.07
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Full resident address o applipnl Address of authorized person