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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R5 / a-03)
PresaiEed by Department ot Local Govemment Financa
Coun Township Year
To beRfiled�'n�person or by mail with the County Auditor of the county where the property is located. �� ��e M� �
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Filing Dates: 1) Real Property: During fhe 72 mon[hs be(ore May 11 of the year the deduction is to be effective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 1 S and March 2 of the year theQ�Ticf�o�is�ig�� ehective.
See reverse side lor addifional instructions and qualifications. � �,
(owner or
Taxing District
O /I--
see restrictiaAB on
S(- �d
Assessed value of real property as of
March 1, current year
If no, what is his / her exact share of interest?
- — �+-
Key r�umber % legal
GIBSOW
number p� �
V
� � Page number � / I �
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Mortgage / Contract indebtedness paid as of Is the applicant the sole legal or equitable
March 1, current yearS`Q Q� Q owner? ❑ Yes ❑ No
It owned with someone other than spouse, indicate with whom.
If name on record is diHerent than that of applicant, indicate below:
of mortgagee or contracl seller
of mortgagee or contract seiler (number and street, city,
of assignee or other owner or holder of mortgage
and street, city, state, ZIP code)
Does applicant own property in any
counry in Indiana?
Deduction approved in the amount of:
I( yes, whai counry7
ZIP
VJhat Taxing District?
COUNTY AUDITOR
�o o� I 20 � I zo� I 2o P
Counly Auditor
„ •.
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Is the property in question:
❑ Real Property ❑ Mobile Home (IC E1.1-7)
Has this deduction been requested on
property for current year? ❑ Yes ❑ No
2� �.
�
Date
20
We certify under the penalry of perjury that the above and foregoing infortnation is true and correct and that the applicants was ! were
�sident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
person