Yes No
STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R13 / 10-15)
Prescribed by Department of Local Government Finance
County
Township
Year
File Mark
Applicant (owner or contract buyer - see restrictions on reverse side)
Record number Page numberTaxing District Key number / legal description
Assessed value of real property as of
assessment date, current year
Mortgage / Contract indebtedness unpaid as of
assessment date, current year
Is the applicant the sole
legal or equitable owner?
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 different than that of applicant, indicate below:
Name of mortgagee or contract seller
Address of mortgagee or contract seller (number and street, city, state, and ZIP code)
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 county
in Indiana?
If yes, what county? What Taxing District? Has this deduction been requested
on property for
current year?
COUNTY AUDITOR
Deduction approved in the amount of:
20 ______ 20 ______ 20 ______ 20 ______ 20 ______ 20 ______ 20 ______
Date (month, day, year)Signature of County Auditor
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 full name)
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7
Address of authorized person (number and street, city, state, and ZIP code)
Full resident address of applicant (number and street, city, state, and ZIP code)
RECEIPT FOR FILING STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
Name of applicant Name of mortgagee or contract seller
Amount of indebtedness Taxing District
Key number / legal description
INSTRUCTIONS:
To be filed in person or by mail.
Filing Dates: 1) Real Property: Must be completed and dated in the calendar year for which the deduction is sought.
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile / Manufactured Homes not assessed as Real Property: Must file with the County Auditor of the county
where the property is located during the twelve (12) months before March 31 of each year the deduction is sought.
See reverse side for additional instructions and qualifications.
Is the property in question: Annually Assessed
Real Property Annually Assessed
Mobile Home (IC 6-1.1-7)
County
Date (month, day, year)
Date (month, day, year)
Date filed (month, day, year)
Date (month, day, year)Signature of County Auditor / County Recorder County
Yes No
Mortgage / Contract indebtedness unpaid as of
date of application
Form filed with:
County Auditor
County Recorder
Yes No
If yes, state amount of deduction
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed $10,000.
A person is not entitled to this deduction unless the person has a balance on the person’s mortgage or contract indebtedness that is recorded in the county
recorder’s office (including any home equity line of credit that is recorded in the county recorder’s office) that is the basis for the deduction.
