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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Stale Fortn 43709 (R4 / 1641)
Presttibed by Depanrtrenl ot Local Govemment Finance
Count Township Year
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INSTRUCTIONS: F E�� �� 20�3
To 6e filed in person or by mail with the County Auditor of the counfy wheie the prope�ty is located.
Filing Dates: 1) Real Property: During the 12 months be%re May 11 of the year the deduction is to be eHaclive. //
2) Mo6ile Homes assessed under IC 6-1.1J: Befween January 15 and March 31 0/ the year� e ded��s�t�be eff��Gve!
See reverse side for additional instiuctions and qualifications. GIBSON CJO�J�T'� AUDITOR �
Applicant (owner co tract buyer - see re riction$ on erse side) ��/�/��/ /�
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Taxing Dislrid Key number / legal description Record number
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oO! ^O// O /^ O� Pagenumber �^ �
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Assessed value of real property a of MoAgage / Conlrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, wrrent year owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interesl? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real Properiy ❑ Mobile Home QC G1.1-n
�ame of mortgagee or contract seller �
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Address of mortgagee or wnlred seller (number and street, city, state, ZIP
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Name of assignee or other owner or holder of mortgage U '
Address of assignee (number and street, city, state, ZIP code)
Dces applicant own property in any other If yes, what wunty? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for curtent yeaR � Yes � No
COUNTY AUDITOR
Deduction approved in the amount of:
20 ,�.3 20 20 O 20 O� 20 � 20 � 20 Qq_
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Signature County Auditor Dale
/ We certify under lhe penalty of pe�jury that the above and foregoing intormation is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners /ull name) Person authorized by duly executed Power of Atlomey
O or by IC 6-1.1-12-.07
uli re�s7idepnt addresQ f appliqnt`/ Address of authorized person
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