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J� � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
��i� FOR DEDUCTION FROM ASSESSED VALUATION Count Township Year
• Stale Form 43709 (R6l 5-06) ' ' � '
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� Resaibed by Oepartment of Local Govemment Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail with lhe County Audiror ol fhe county where the prope�ty is /ocatedAU� .1 '] ZQ�]
Frling Dates: 1J Real P�operty: Dunng the 72 monlhs befo2 ,lune 17 o(fhe year the deduction is to be elfective.
2J Mobile Homes assessed unde� IC 6-7. 7-7: Between January 15 and Ma�ch 2 of they�g� the ��n is to be effective.
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See reverse side for additional instiuctions and qualifications. r,IBSON COUNTY AUDITOR
Appliwnt
Taxing
buyer- see restrictions on reverse
Assessed value of real property as of
March 1, current year
If no, what is his / her exad share of interest?
Key number / legal
Record
Page number
� -sb-yW-� aos�oa, �b -
Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrrent year owneR "' ❑ Yes 0 No ''
� �(o I . D � .
Ii owned wilh someone other than spouse, indicate with whom.
If name on record is different than ihat of applicant,
moRgagee or contrad seller
Address of mortgagee or contrad seller (number and stieet,
Name of assignee or other owner or holder of mortgage
Addceas of assignee (num6er and stieet, city, state, ZIP
Dces applicant own properfy in any other I If yes, what
county in Indiana?
Dedudion approved in,the amount of:
20��' 20 20
�
Signature
below:
state, ZIP
Is the property in queslion:
� Real Property .❑ Modle Horrie pC 61.1
� _ �
What Taxing Distrid?
COUNTY AUDITOR
�
County Auditor
20
M
Has this dedudion been requested on
property for current yeaR �] Yes❑ No
�
Date
20
certify under the penalty of perjury thal the above and foregoing information is true and corred and that the appiicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
ire�wners �me)�^ '— Per� n authorized by duty executed Power of Attomey
p� or b IC 6-1.1-12-.07
applicant Address of authorized person
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