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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
' • FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S � J State Form 43709 (R4 / 70-Ot ) �� �,r�
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Prescribed by Depanmenl of Local Govemment Finance
INSTRUCTIONS: NOV � 6 ���a�x
To be filed in person or by mail with the County Auditor o/ the county whe2 the property is lo fed.
Filing Dates: 1) Real Property: During the 12 months befo2 May 11 0l fhe year the deductio s to be ffe ive� �
2J Mobile Homes assessed under IC 6-1.1-7: Behveen Janoary 15 and Ma�ch 3 �! cGo s to'be ef/ective.
- -IBSON OUNTv AUDITOR �
See reverse side /or additional instiuctions and qualifrcations.
Applica 1( r or contract buyer - ee.re n ions on revers ide)
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Taxing District Key number / legal description Record number
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�' Page number � C � �
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Asse sed value real prope s of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
MarcF� 1, wrrent year March 1, cunent year owner? ❑ Yes ❑ No
ia ��o,
If no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different lhan that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ MobBe Home (IC fr1.1-�
�me of moRgagee or contract seller ��
Address of mortgagee or contrac[ seller (number and st2et, city, state, Z!P
Name of assignee or other owner or holder oi mortgage
Address of assignee (numberand street, city, state, ZIP code)
Does appliqnt own property in any other If yes, what county? What Taxing District? Has lhis deduction been requested on
county in Indiana? property for curcent yeaR � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of: �
20 �_ zo zo c� zo n � zo a Y zo �_ 20
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Signature � County Audftor Date
�/ We certify under the penalty of perjury that the above and foregoing infortnalion is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners lull name) Person authorized by duly executed Power of Attomey
� or by IC 61.1-12-.07
Full resi ent ddress of applipnt Address of aulhorized person
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