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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS � �—, --"�
' FOR DEDUCTION FROM ASSESSED VALUATION Coun [� ii Township� i, Year
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�'+ J $tate Fwm 43709 (RS I d-03)
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� PrescnDetl by Departmeni of local Govemment Finance J U " 200!
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INSTRUCTIONS: K/.. ��ile�Mark
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To be filed in person or by mail with the CountyAuditor of t6e county whe�e the property is located. GISSON COUNTY hth7ITC:;
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year the deduction is to be eflective.
2J Mobile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 of the year the deduction is to 6e effective.
See 2verse side for additional instructions and quali�cations. �\
orcontra�f buyer- see
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Tauing �strict �
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Assessed value of real property as of
March 1, wrrent year
if no, what is his / her exact share of interest?
number I legal description � Record
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Mortgage / ContraU indebtedness unpaid as of Is the aoplicant the sole legal or equitable
March 1, current ye2r/ owne(? ❑ Yes ❑ No
If name on record is different than ihat of applicant, indicate below:
mortgagee or contract seller
Address of mortgagee or contrad seller (number and street,
Name of assignee or other owner or holder of :nortgage
Address of assignee (number and street, city. ;;ate, ZIP code),
Does applicant own property ir any cdher I If yes, what co!;aty?
county in Indiana? �
Deduction approved ir the amount of:
20 � '�'
SignaWre
20
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owned wi�h someone other than spouse, indicate wiih whom.
❑ Real
state. ZIP
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❑ Mobile Home (IC 61.1
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COUNTY AUDITOR
20 �� i 20 _�4 20
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County Auditor
20
20
ion
� No
�/ We certify under the penalty of perjury ihat the above and teregoing information is true and correct and lhat lhe applicanls was / were
resident of Indiana and owner of the aforementioned property on March �. 20
Signature (owners full name) Person auihorized by duly executed Power of Attorney
./ ��.,a9_ � 7,f.—i o� by ic s-i.i-iz-.o�
resideni a5dress of applicant
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of authorized person