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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�S / Sfate Form 43709 (RS / 4-03) �
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� Prescnhed 6y Departmem al Local Govemment Finance E� �1 Ii (� � �
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INSTRUCTIONS: AUG 2 �;i2��
To be filed in person or by mail with the County Auditor of the county where tAe property is located.
Filing Dates: 1) Real Property: During the 12 months 6efore May 11 0/ the year the deduction is.to�be effective. /�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of th/e��y�ear. the.deiiuctron i�s,�to� b�e�� eyHective.
See reverse side for additional instructions and ualifications � /G ^�� ���J�� �.`I
4 GISSON C�'��"lT'+ 41!DIiC� .
Applicant (ownerorcontr buyer- seelesMction n reve de ^
Taxing Distrid Key number / legal description Record number
I I/� ��^Q /�/��.� Page number O�
�J '� 7
Assessed value of real property as of MoRgage / Contract indebtedness unpaid as of Is the applicant the soie legal or equitable
March 1, wrrent year March 1, current year owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different lhan that of applicanl, indicate below: Is the property in queslion:
� ❑ Real Properly ❑ Mobile Home (IC 61.1-�
��e of mortgagee or contracl seller �� /�
Cb MO(1 w c �
Address of mortgagee or contract selier (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st�eet, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for cunent year7 � Yes� No
COUNTY AUDITOR
Dedudion approved in the amount of:
20 � 20 � 20 �� 20 20 20 20
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Signature Counry Auditor Date
�' We ce � under the penalty of�perjury thai the above and foregoing information is true and correct and thal ihe applicants was / were
es' nt of Indiana and owner of the aforementioned property on March 1, 20
natur owners lull me Person authorized by duly executed Power of Attomey
or by IC 6-t.t-12-.07
F eside ddress o pgjj,�a� � ` ddress of aulh�d person
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