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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
• w� / State Fwm 43709 (RS / 4-03) .
� Prescnbed by Depanment o( Local Govemment Finance
�
iNSrRUCnoNS: APR 2 � F;ie Ma�
To be (led in person or by mail with fhe County Auditor of the county where the property is located. 20�6
Filing Dafes: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is to be effective.
2) Mobile Homes assessed under IC 6-1.1 J: Between January 15 and March 2 0( the yeaFfhe deductron is to 6e eHective.
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See reverse side Ior additional instructions and qualifications. GBSOnI CO{ N7v � I70R
Applicant
Taxing
Assessed va7ue of real property as of
March i, current year
If no, what is his / her exact
on reverse side)
Key number / legal description
6// -GY j
Mortgage / Contrad ii
March 1, current year
If name on record is different than that ot applicanf,
of mortgagee or contracl seller
below:
Record number
Page number
unpaid as of ( Is the applicant the sole legal or
owner? ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
Address ot mortgagee or contract seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
(number and street, city, state, ZIP
Does applicant own property in any other If yes, what county? What Taxing
county in Indiana?
��y� �� J � 2 .� COUNTY AUDITOR
20 � j
1
Signature
approved in the amount
� •�.
20 �_ 20 20
�
County Auditor
Is trie property in question:
❑ Real Property ❑ Mobile Home (IC 61.
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Drawer NO ......:.: .......... � o„
' � No
Card NO . ............ �.....:..
o2C� 0 ,6 �. �6 9 S!
20
Date
20
We certify under the penalty of peryury that the above and foregoing information is true and corred and that the applicants was / were
�esident of Indiana and owner of the aforementioned propeRy on March 1, 20
/ull
Person authorized by duly
or by IC 6-7.1-12-.07
resident add�ss of applicant � (Address of authonzed person
Attorney