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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' F�JR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
o M� I State Fortn 43709 (RS / a-03) . , . : - " , . . . { ' � � �
� PrewibeE by Department of Lofal Govemment Finance - �
INSTRUCTIONS: ' MAR O 3 ZQQ� Mark
To be /iled in person o� by mail with the County Auditor of the county where the property is located. -,
Filing Dates: 1) Real Property: During the 12 montbs before May 11 0/ the year the deduction is to f,��cti��
2) Mobile Nomes assessed under IC 6-1J-7: Between January 15 and March 2 of the year �e dedu6fion is to be eNective.
See 2verse side for additional instructions and qualifications. � G�gSON COUNTY AUDITOR
Applicant
Taxing Districl �
V' � ��./ (,(.�/ /�
Assessed value of real property as of
March t, wrcent year
Ii no, what is his / her exad share of
side)
Key number / legal description � Record number
a
/1� ) � ,�, j��yo� � Page number D
��./ � �f(/
Mortgage / Contrad indebtedness unpaid as of Is the applicanf the sole Iegai or equitable
March 1, current year . owner? ❑ Yes ❑ No
O
If owned with someone other than spouse, indicate wilh whom.
If name on record is different ihan that of applicant, indicate
of mortgagee or coniract seller
of mortgagee or conlrad seller (number and st2et�city state, ZIP
of assignee or otNer
Address of assignee
or
and street, ciry, state, ZIP code)
Dces appliwnt own property in any other If yes, what county?
county in Indiana?
Deduction approved in the amount of:
20
Signature
COUNTY
s the property in question:
❑ Real Property �.p Mobile Home (IC 61.1-
n .i � .
'.� . . • •-
Dra�r�er NO.....�? 1�b.4o:��.
oZ00,s � $09 (
Card I�iO . ..................
CG,,,a Q, y�°'+-b�-� �o o �
�r'�.� ��t 6E,r'�'
�� 20 � `i � 20 20
P �°
__ County Audilor
20
Date
=en requested on
ea(? � Yes ❑ No
20
We certify under the penalry of perjury that the above and foregoing information is true and corred and that ihe applicants was / were
residenl 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
ss o� appucarn Address of authorized person
S Ce/�� � �'