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a.� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
sa�'`' FOR DEDUCTION FROM ASSE$SED VALUATION
�jJ State Form 43709 (R6 / 5-OG1 �
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� Resaibed by Depanment of Local Gwemment Finance
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INSTRUCTIONS:
To be (iled in person o� by mail with the County Audito� ot the county where the property is located1I�,1
Filing Dates: 1) Real P�operty: During the 12 months befom June I7 of fhe yea� the deduction is tdbL�f�r$va-0p�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of th,e year lh�eduction is to be eflective.
See reverse srde for additional instnictions and qualifications. �� �
GI6SON CO�NTy q�p�TOR
Taxing
t buyer-
Assessed value of real property as of
March 1, curtent year
no, what is his / her exact share of interest?
If name on record is diHerent than
of mortgagee or contract seller
reverse
/legai
March i, currenl year
indicate below:
unpaid as
Record number _ -
Page number
Is the applicant the sole legal or equitable
ownef? ❑ Yes ❑ No
�, Gbc� �
If owned with someone ofher lhan spouse, indicate with whom.
Address of mortgagee or contracl seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and st2et, city, state,
Does applipnt own property in any other If yes, what counry?
county in Indiana?
Deduction approved in the amount of:
20 e�
Signature
20 �
❑ Real
v e /u
n question:
r ❑ Mobile Home QC 61.1-�
n � I I
? 3 �a�
Dra„�cr \o�• .-. .
Wh� �.:11"(� \� . ..................... :questedon
0�� � ///�, �� OU ❑Yes❑No
o�
COUNTY AUDITOR
20 20 20
County Auditor
20
Dale
e7i7
We certify under lhe penalty of perjury that the above and foregoing informalion is true and corred and thal the applicants was / were
esident of Indiana and owner of lhe aforementioned property on March 1, 20
��ature (owners /ull name) Person authorized by duly executed Power of Attomey
i.�—�— ��,�,N �,c}� �t,�/ or by IC 6-1.1-12-.07
Full
of aoolipnt
�. C.14� � S�= (i,.�L�S-�\l� S',�.
Address of authorized person