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�'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES').V�',YJflI '!S!ifFship Year
a FOR DEDUCTION FROM ASSESSED VALUATION
LidStater Form 43709(Rill/6-09)
Prescribed by Department of Lod Government Finance /
e t File Mark
INSTRUCTIONS:
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To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is fora d. •
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Filing Dates: 1) Real Property Must file during the year for which the deduction is sought t,� 1 t my Auditor
2) Mobile/Manufactured Homes not assessed as Real Property:Must file during the tweA�, Ogpt%) County Recorder
before March 31 of each year the deduction is sought Ci
See reverse side for additional instructions and qualifications.
Applicant(• ..p.. . ..buyer-see restrictions• • : side)
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Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the applcant the sole
March 1,current year Marchhneet year date of application ' legal or equitable owner?
❑ Yes ❑ No
If no,what a his/her exact share of interest? I t owned with someone other than space.indicate with whom
If name on record is different than that of applicant.Indicate below. - — -- nu scion:Annually Assessed
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Name of mortgagee or control seller
1
Address of mortgagee or contract seller(number and street ray.scam, LP code) )-9039
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,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? ❑ Yes ❑ No f a ❑ Yes ❑ No
COUNTY AUDITOR
Deduc on approved in the amount of:
20 20 20 20 20 20 20 •
Signature of�CCounntty�A,udi�torr ���J - County Date(month,day,year)
IWe n`y under try `y of p___.
I/We certify under the penalty of perjury that the above and knegoing information is true and correct and that the applicant is a resident of Indiana and
owneri_cortract buyer of the aforemen. property on da pplication is filed.
xil SIgnatue(ownees 91 name) or
Date(nth,day.year)
di
FutF�gen�addtESS of applicant(n rand street,ct7Y,state.aM /`L • OC 11 1 le 1 O
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 / r Date(month,day,year)
Address of authorized person (number and street,city,state,and ZIP code) .