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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
� J State Fwm 43709 (RS / 4-03)
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P2saiDeE by Department of Local Govemment Finance �' � l��
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INSTRUCTIONS: AUG O �11e�t1�
To 6e filed in person or by mail with the Counry Auditor ol the county where the property is located.
Filing Dates: i) Real PropeRy: Dunng the 12 months before May 11 oI the year the deduction is to�be eBective./ � n �
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and Maich 2 0/ the year the deduction �s to 4e eflective.
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See reverse side for additional insWctions and qualifrcations � GI3SON CODUr� qUDITOR 1
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Applicant (o �orcontract buyer- see resMction n reverse side) .
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Taxing Distrid Key n ber / legal desc,ri� {tion �7 Rewrd number �
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Assessed vatue of real property as of MoAgage / Contract indebtedness unpaid as of Is the applirant the sole legal or equitable
March 1, current year March t, rent year owneR ❑ Yes ❑ No
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Ii 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 applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home QC 61.1-�
�me of mortgagee or contraIX seller
Address of mortgagee or contrad seller (number and street, city, st , ZIP
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Name of assignee or other owner or holder of mortgage
Address of assignee (numberand street, city, state, ZIP code)
Does applicant own property in any other If yes, what counry? What Taxing Distrid? Has this deduction been requested on
county in indiana? property for wrrent yea(? � Yes� No
COUNTY AUDITOR
Deduc6on approved in the amounl of:
20 20 20 �� 20 � 20 �� ' 20 �_ 20
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Signature County Auditor Date
;�'! We certify under the penalty of perjury lhat the above and foregoing infortnation is true and correcf and that the applicants was / were
:esidenl of Indiana and owner of the aforementioned propeAy on March 1, 20
S' ture (owner's lull name) Person authorized by duly executed Power of Attorney
a � �/� a or by IC 6-1.1-12-.07
Fu re dent a dress of applicant Address of authorized person
co0) s, I+�:II St.