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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
,+ J State Fwm 43709 (R5/4-03)
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� PrescnEed Dy DepaM1mem of Local Govemment Finance �'; i � ����
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INSTRUCTIONS: J U �Fill Ma�004
To be (led in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months be%re May 11 0l the year the deduction is to 6e ef� ctive. �
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and Maich 2 0/ the yea� fhe deduction is f be effectiven
See reverse side Ior additional instructions and ualifications. � a �' �`��`�- �,���
Q GI.,SON CQU\TY �1.,. T�
or contracf buyer
Taxing Disldc`E // Key number / legal description Record number
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( \)�(y�/n/V��,�� O�Q _ ��Q ���V Page number 0�
`_t. v/ n....��
Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, cunent year March 1, current year 5� ���� � owneR ❑ Yes ❑ No
If no, what is his / her exacl share of interest?
If name on record is different than that of applicant, indicate below:
�ame of mortgagee or contract seller
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Address ot mortgagee or conlrad seller (number and street, city, s
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other I If yes, what counry?
county in Indiana?
Deduction approved in the amounl of:
20
Signature
20
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owned with someone
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spouse, indicate wilh whom.
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❑ nnoa�e H«ne nc �,.,
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What Taxing Distrid? Has this deduction been requested on
propeAyforn��--• --��QYes�No
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couNrir � Dra«'er
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Card �'�05� � • p—_
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County Auditor
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Dafe
20
/ We certify under the penalty of perjury that the above and foregoing information is lrue and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
�re (ow�n/ers full name)
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;ident address of applicant
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Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person