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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
: w� ♦ State Form 43709 (RS I 4-03) . . �
�� Prescnbed by Depanment ol Laral Govemment Finance �
Coun Township Year
INSTRUCTIONS: i QQ�a �
To be filed in person or by rriail with the County Auditor of the county where the property is located. MAR 2��"0
Frling Dates: 1) Real Property: During fhe 12 months before May 11 of the year the deduction is to be eflective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the yea���de�dual �� to 6e effective.
See reverse side for addifional inshuctions and qualifications. C-i
. GIBSON C6UN7V AUDITpR
Applicant (owner.orcontracf 6uxer- see
Taxing Distrid
K�/ClJ�LI/w� lX
Assessed value of real property
March 1, current year
no, what is his / her exact share of
on
Key q(uJnber / legal
Record
��/ _ Q //� 3 �� Page number
l(J l
Mortgage / Conlrad indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, curtent year . ownef? ❑ Yes 0 No
, . � ? �fl • .
If name on record is different ihan that of applicant,
'me of mortgagee or contrad seller /� /•
beiow:
If owned wilh someone other than spouse, indicate with whom.
Address of mortgagee or wntraIX seller (number and st2et, city, state, ZIP
Name of assignee or other owr
(number e � O�W� � � �.i �,(J !
Is
❑ Real Propelty ❑ Mobile Hmie QC 61.1-�
Does applicant own property in �_�_3 V�_. �� this dedudion been requested on
coun m Indiana? �
b' �erty for current year? � Yes ❑ No
Deduction approved in the amc
20 � � 20.
Signature _
We certify under the penalty
.resident of Indiana and owne
Signature (owners lull name)
`h
F�u�il resident ad ss of applicant
X i�il f�. [_� nfrf��n.
�..l�r
Q G�K.�(i�1
20
nd thal lhe applicants was / were
rerson auinonzea �y auiy executed Power of Altomey
or by IC 6-1.�1-12-.07
of authorized person