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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
� w� ! State Fwm 43709 (R5/4-03)
�, PreunCed Oy Department of Loral Govemmenl Finance
Coun Township Year
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INS7RUCTIONS: OCj 1 ����
To be filed in person or 6y mail with the County Auditor o! the county whe�e the property is located.
Filing Dates: 1J Real Property: During the 12 months before May 11 o1 the year the deduction is to be eflective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Maich 2 01 the year �e�de� � rr�ko be eHective.
See reverse side for additional insfructions and quali(cations. G�gSON COUNTY AUDIT�R
Applicant (owner or cont2ct
Taxing
Assessed value of real property as of
March 1, wrrent year
no, what is his / her exaa share of
:nons rever side) G� ,_ I v/l�/G{/���
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Key number / legal description Record number
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b � S-oi�a s�a Page number
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Mortgage / Conlrad indebtedness unpaid as of Is the applicant the sole legal or equ
March 1, current year ownef? ❑ Yes � No
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If owned with someone other than spouse, indicate with whom.
If name on record is diHerent than that of applicant, indicate below:
of mortgagee or contrad seller
of moRgagee or conlract seller (number and street, city,
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand street, city, state, ZIP
Does applicant own property in any ofher If yes, what county?
county in Indiana? .
Deduclion
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Signature
in the amount of:
20 �_ 20
i
ZIP
What Taxing District?
COUNTY AUDITOR
20
County Auditor
20
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❑ Real Propery ❑ Mobile Horne pC 61.'
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Has this dedudion been requested on
property for current yea(?� Yes� No
20
20
certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
Full resident address of applicant
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Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
of authorized person