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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
State Fortn 43709 (RS / 4-03)
PmstriCed Uy Department of Local Govemment Finance
INSTRUCTIONS: AQR Q 1 Ftf��a�
To 6e �led in person or by mail with the County Auditor of the county where the propeRy is located.
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to be elfective.,(�
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the ye��ducY�i��� effective.
See reverse side for additional inshuctions and qualifications. G18SON �OUNT
A licant (owne� or conlract buyer- ee restrictio on reverse si e)
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Taxing Dislrid K number / legal description Record number
��� 0 5- 7
C�o q- a 3 a 3�- � Page number
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant ihe sole legal or equitabte
March t, current year March 1, current year . owne(? ,�Yes ❑ No
0 ooa
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 than that of applicant, indicate below: Is lh pr�n question:
❑ ea ❑ Mobile Home (IC 61.1-�
e of mortgagee or contrad selle�
Address of mortgagee or contred seller (number an stieet, city, state, ZIP
Name of assignee or other owner or holder of morigage ��
Address of assignee (num6erand st2et, city, state, ZIP code)
Does applicant own property in any olher If yes, what county? What Taxing District? Has this deduction been requested on
counry in Indiana? property for currenf year?� Yes� No
COUNTY AUDITOR
Deduction approved in the amounl of:
20 20 20 �_ 20 20 20 20
Q � P
Signature County Auditor Date
We certify under ihe penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
sident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners (ull name) Person authorized by duty execuled Power of Attomey
� c � or by IC 6-1.1-12-.07
Full resident address of app i nt Address of authorized person
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