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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�+ ! Siate Form 43709 (RS / 4-03) '}t�.�� �� �
� 4� Prnscribed by Depanmem of Local Guvemment Financa �—.� � �}� �
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iNSrRUCriorvs: JUN k;ie��
To be filed in person or by mail with the CountyAuditor of the county where the property is located. � /J „ /�
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is to be e/%ctive. ���� �� ��
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2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0( the year the deducfio`n is'to beteflechve.
See reverse side for additional instructions and qualiTcations.
�� GI5SON CGUi2 t Y hV.+�
or con
Taxing Disirid
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Assessed value of re!
March t, cunent year
side)
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�.ay number / legal description
�l� -��
as of MoAgage / ContraG ir
March 1, current ye2r
If no, what is his / her exact share of interest?
Record
Page number
unpaid as of Is the applicant the sole legal or equitable
owner? ❑ Yes ❑ No
owned with someone other than spouse, indicate with whom.
If name on record is different than Ihat of appliwnl, indicate belovr.
itame of mortgagee or contract seller
�
Address of morigagee or wntract seller (nu be and str�et, city, state. ZIP
Name of assignee or
Address
owner or holder of mortgage
(numberandstreet, city, state, ZlPcode)
Does applicant own property in any other I I; y�s, «•hat county % � 1N �ai Taxing Distrid?
county in Indiana? �
Deduction approved in the amount of:
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Signature
20 /J{� I 20
COUN � Y AUDITOR
20 _ 0 7f � 20
P I P
County Auditor
s the property in question:
❑ Real Property ❑ Mobile Home QC Cr1.1
Has this deduction been requested on
propeAy for current year? � Yes � No
�
Date
20
ify under the penalty of perjury that the above and feregoing information is true and corred and that the applicants was / were
of Indiana and owner of the aforemer.tioneC property on March i, 20
¢�l�ers full na�� `�/ Person authorized by duly executed Power of Attorney
?z%�'�/U/ . iYw _ or by IC 6-1.1-12-.07 ,
• , � � � ��dr� of authorized person
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