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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�� �� / State Fortn 43709 (R514-03) —.� �
� PmscnDeO b De riment of Laal Govemment Finance .'j.� — �l �((� —_.
Y Pa IA ll ~ � /i
wsrRUCnoNS: MAR 3IF�16�$�
To be filed in person or 6y mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 montbs be%re May 11 0/ the year the deduction is be eHective: Q n n
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0l e�ear tAe-deductwnjs�o�6e eNective.
See reJerse side for additional instructions and qual�cations. �° GI°SGN COU�li Y�UCfT^ -. .
Applicant (oy�ner or contract buyer - see
Taxing Distrid
Q� /.�i�a��
Assessed value of real property as of
March 1, curtent year
If no, what is his / her exact share of interest?
If name on record is different than that of
of mortgagee or contrad
Key number / legal description
0//- O/07"Q -�
Mortgage / Contract ir
March 1, current year
Address of mortgagee or contract seller (number
indicate below:
Name of assignee or other owner or holder of mortgage
Address of assignee (num6erand street, city, state,
as
Record number s,OO �
OC.
Page number //�{
d
Is the applicant the sole legal or equitable
ownef? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
city. state, ZIP
code)
Does applipnt own property in any other if yes, what county?
county in Indiana?
Deduction approved in the amount of:
�
20 �_ I 20 � � I 20
G
What Taxing District?
COUNTY AUDITOR
20_Q� 20 6�
7 r7
("
County Auditor
s the property in question:
❑ Real Property � Mobile Home QC G1.1-�
Has this deduction been requested on
property for current year? � Yes❑ No
20
Dale
20
/ We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned properiy on March t, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of applicant , _ �Address of authorized person