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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Siale FoRn 43709 (R4/ 10-01)
Prescribe0 by Departmenl of Loral Govemment Finance
Count Township Year
� RUCTIONS: Fi a
To be filed in person or by mail with the County Auditor o/ fhe county whe2 the property is Iocatec� ����
Filing Dates: 1) Real Property: During the 12 months be/o2 May 11 0/ the yea� the deduction is to be elfective.
2J Mobile Homes assessed under IC 6-1.1-7: Befween January 15 and March 31 of the ye�� c�ductiprµs to be eNective.
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Applicant (owneror contract buyer- se restnctions on reverse side) GI9SON COUN? v AUDITOR
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Taxing District Key number / legal description Record number _ ,`
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Page number
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owner? ❑ Yes ❑ No
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If no, what is his / her exact share of interesl? If owned with meone other than spouse, indicate with whom.
If name on record is different lhan that of applicant, indicate below: Is the property in question:
❑ Real Pmperty ❑ Mobile H«ne (IC 61.1-�
N�ame of moAgagee or contract seiler
th 3 rd
Address of mortgagee or contraIX 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 applipnt own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for current year? C� YesO No
COUNTY AUDITOR
Deduction approved in the amounl of:
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Signa ure � County Auditor Date
I/ 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 .
nature ( ers (ull me) Person authorized by duly exewted Power of Atlomey
or by IC 6-1.7-12-.07
Fu r id address o pplicant Address of authorized person
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