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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNES$
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R4 /70-01)
PrescriDeO Dy DepaM�enl ol Local Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located. � p{� � 7 Z��3
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is l0 6�'Aflec6ve.
2) Mobile Homes assessed under IC 6-1.1-7: Befween January 15 and March 31 0/ the year the dce..�duction i/s to/6/e e/%ctive.
See reverse side lor additional instiuctions and qualifications. ����' v�f� X
' GI3SON C�'?Ut�T�' ����TOR �
Applicant
Taxing Distrid
6uyer - see r,�sfricti44s on reverse side)
Assessed value of real property as of
March t, curcent year
/ legal description
001-QIS
MoAgage / Contract ii
March 1, currenl year
Record number
Oa-`�O
Page number
as of Is the applirant the sole legal or
owneR ❑ Yes ❑ No
a; Oooa
I( no, what is his / her exact share of interest? If owned with someone other ihan spouse, indicate with whom.
c?�-�a /S�aa - 60% �l �-c�/
If name on rewrd is different ihan thaf of applicanl, indicate betow: Is the property in question:�
mortgagee or co�S[Tpd seller
Address of mortgagee or contrad selier (�umber and street, city, state, ZIP
Name of assignee or other owner or holder oi mortgage
Address of assignee (numberand sVeet, city, state,
Does applicant own property in any other If yes, what counry? What Taxing
county in Indiana?
Dedudion
zo�
the amounl of:
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COUNTY AUDITOR
2� 20 2�
Counfy Auditor
p�- �0.2�
zo � I2o
Date
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/ We certify under lhe penalty of peryury that the above and foregoing infortnation is true and corred and that lhe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
name)
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person
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