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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�'+ I State Fortn 43709 (R5 / d-03)
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PrescriDed by Department of Local Govemment Finance
INSTRUCTIONS: uu `��
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To be filed in person or by mail with the CountyAUditor of the counry whe2 the propeRy is located. i, %
Filing Dates: 1) Real Property: During the 12 months 6efore May 11 of the year the deduction is to ef(ective.
2) Mobile Homes assessed underlC 6-1.1-7: Between January 15 and March 2 0l the year tq1e,ded �tien �e effective.
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Applicant (ow or contract buyer - see resMCF s on reverse side ' -a �;,r1 •: a+�p�+ wn •
) G�BSO�� Cni. � .
Taxing District ey number / legal descrip ion Record number �
��� i i%/ C� � Page number ��
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equita6le
March 1, current year March 1, current year owner? ❑ Yes ❑ No
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It no, what is his / her exact share of interest? If ovmed with someone other than spouse, indicate with whom.
If name on rewrd is different than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home pC 61.1-7)
e of mortgagee or contract seller �
Address of mortgagee or contract seller (number and street, city, state, ZIP
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 If yes, what county? What Taxing District? Has this deduction been requested on
county in lndiana? property for curtent year? � Yes � No
COUNTY AUDITOR
Deduction approved in the amouni of:
2o zo D 5 20 � 2o Q'1 zo � zo �Q_ zo
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S�gnature County Auditor Date
' We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
i e(owners full name) Person authorized by duly executed Power o( Attorney
or by IC 6-1.1-12-.07
Full e'dent addre� applicant Address of authorized person
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