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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
+�w J Stata Fortn 43709 (RS / 4-03)
� PrescnDed by Depanment ot Laal Govemment Finance
INSTRUCTIONS: --� � �Filg�a .r12 �
To be filed in person or by mail with the County Auditor of the county where the property is locate� �iJ �
Filing Oates: 1J Real Property: During the 12 mon[hs 6efore May 11 of the year the deduction is to be eflective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Maich 2 of the yeard(ie(?leauctic��o be effective.
oee reverse s�oe ror aoomona� msrrucnons ana qua�mcanons.
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Applicant (o erorcontracf 6uyer- see resMcti on reverse side) �` GIBS • cvun �� ���. � �• ••
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Taxing Distrid Key number / legai description Record number
� (� 3- 1� �
6 1�_ OU � -� Page number
Assessed value of real properiy as of MoAgage / Contrad indebtedness unpaid as of Is the applicant t sole legal or equitable
March 1, current year March 1, current year owneR Yes ❑ No
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If no, what is his / her exad share of interesl? If owned with someone other than spouse, indicate with whom.
If name on record is different than thaf of applicant, indicate below: Is the property in question:
eal Property ❑ Mobile Home QC 61.1-n
�ame of mortgagee or contraG seiler (�
O/ /
Address of mortgagee or contrad seller (number and street, city, tate, ZIP �� _ 3' yQ
/
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand street, city, sfate, ZIP code)
Does applicant own property in any other If yes, what counry? What Taxing District? Has this dedudion been requested on
county in Indiana? property for current year? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 �,� 20 � 20 O 20 O� 20 �. 20 20
� / �
SignaWre County Auditor Dale
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�/ We certity under the penalty of perjury that the above and foregoing information is true and corred and thal the applicants was / were
resident of Indiana and owner of the aforementioned propeRy on March 1, 20
Sig atur o� ers full name) , Person authorized by duly exewted Power of Attomey
or by IC 6-1.1-12-.07
F I resid nt a dress of�appl�cant Address of aulhorized person
50 �