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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S / State Fwm 43709 (RS / 4-03) � �
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� Prescnbetl �y Depanment of locat Govemment Finance ��j �'a �{J i,
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INSTRUCTIONS: JUL � �'�Qg�
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Pioperty: During fhe 12 months before 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 March 2 o/the ye�d� tion Is.to he;effective.
See reverse side for additional instructions and qualifications. � Gi3SON COU���T" A��17G'� 4
Applicant (owner o ntra t buyer- see resMctions on reverse side)
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Taxing Dislrid Key nu er / legal description Record number Q
VV �' � -DD�6�f�Ob Pagenumber ��
Assessed value of real property as of Mortgage / Contrect indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrtent year March 1, wrrent year ownef? ❑ 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 than that of applicanf, indicate below: Is t property in question:
Real Property ❑ Mobile Home pC 61.1-�
�e of mortgagee or conlract selier
Address of mortgagee or contrecl seller (number and st2et, ity, state, Z!P
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, sfate, ZIP code)
Does appiicant own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for current year? �] Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amounl of:
20 20 �� 20 �$_ 20 O 9 20 20 20
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Signature County Audilor Dale
� We ce ify under ihe penalty of perjury that the above and foregoing informalion is true and correcl and that the applicants was / were
�si ni of Indiana and owner of the aforementioned properly on March 1, 20
Sig ture owners lull name) Person authorized by duty executed Power of Attomey
or by IC 6-1.1-12-.07
ull si en s f a plicant Address of authorized person
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