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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R11/6-09)
f ) eFil
Prescribed by Department of dotal Government Finance
INSTRUCTIONS:
Fain Ned with:
To be filed in person or by mad with the County Auditor or County Recorder of the county where the property is located. n177
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought. Mt 8 CotLtCUuditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months
before March 31 of each year the deduction is sought ❑ County --•• •• 4--n
See reverse side for additional instructions and qualifications. n' I • Omni
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Applicant r contract buyer-see restddi p n °°eeoonn d • Qui1..P/h Omni ,7�S 1 , • 1 • i -
Taxing D'tsniti r%r/�,�/ N G �, -OD 3,38 2 icle 3a
Assessed value of real property as of Mortgage/Contract Indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1.current year March 1, t year date of application legal or equitable owner!
I O ti DO ❑ Yes ❑ No
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 dfierent than that of applicant India at:below fs the property in question:Annually Assessed
❑Real Property ❑AnnuadyA.ssessed
Mobde Home(IC 61.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contact seller(number and street,may.state,and�)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,an
Does applicant own property in any other s x)13 Has this deduction been requested on property
county in Indiana? for current year?
0 Yes ❑ 1!/No Drawer NO _ ❑ Yes ❑ No
Deduction approved in the Card NO. I 3�
ed m
20 20 N 1 20 20 20 20
Signature of County Auditor County Date(month,day,year)
I I We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner,A!contract buyer of the aforementioned property on date application is filed.
/ Signantraio / Date(month,day,year)
�is;en adpdressoa ,umber and f city,state,and ZIP code)
Wrorized by duty executed Power of Attorney or by IC 61.1-12-0.7 . ' Date(month,day,year)
Address of authorized person (number and street,city:state,and ZIP code) .