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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year -
I-tFOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R11/6-09)-
Prescribed by Department of IlCal Government Finance
File Mark
giNSTRUCTIONS:
To be filed in person or b mail with the County Auditor or County Recorder of the county where the Form coed with:
Y N property is located.
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought. ❑ County Auditor
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 Recorder
See reverse side for additional instructions and qualifications.
Apr nt( r or cmtratt po�e ,sf/rtroris core side) -•
Taxing 0' s/ number/ r Record n m Page number
"cD - l$ i ' %D3- p ,00 . 39l- 33x7 _
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Conuact indebtedness unpaid as of Is the applicant the sole
Mardi 1,current year Mar h 1,current year data of appfmatinn legal or equitable Owner?
❑ yes Duo
If no,what is his/her exact share of interest? t V uv If owned with someone other than spwce,indicate with whom
If name on record is different than that of applicant,indicate below. . Is the property in question:Annually Assessed
3 ❑Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(number and street ray,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street thy,stare,and ZIP code)
Does applicant own property in any other If yes,what county? What Taring District? Has this deduction been requested on property
county in Indiana? for current year?
❑ Yes ❑ No ❑ Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor County Date(month,day,year)
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/contract buyer of the aforementioned property on date application is filed.
Signature(owner's MI name) Date(month,day,year)
Full resident address of applicant(number and street city,state,and ZIP code)
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and steel,thy,state,and ZIP code) .