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;i "� STATEMENT OF MORTGAGE OR CONTRACT INDE3TEDNESS
���' FOR DEDUCTION FROM ASSESSED VALUATION Count Township Year
i� State Form 43709 (R6l 5-06) . � - � .
�«• Presrnbed by Department of Loml Gwemment Finaixe �
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INSTRUCTIONS: c� �'��Mark
To be filed in person or by mail with the County Audilor ot the county where fhe property is located. � PN
Filing Dates: 1) Real Property: Dunng the 12 months before June Il o/ the year the deduction is to be eflective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Ma�ch 2 oI the yearti�'�on�'��'effective.
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See �everse side lor additional instnictions and qualifrcations. G`BSON CpUN
App' M(owner or contract buyer- see restrictions on reverse side)
Taxing trid Key number / legal description Record number
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� �— c7,%-la. - I ST-LO 2�3 �(L�a � age number
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applican�,tfye sole legal or equitable
March 1, current year March t, cunent year owneR ��I Yes ❑ No "" "
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If no, what is his / her exacl share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that ot applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-�
�ne of mortgagee or contrect seller �
Addreas of moRgagee or contred seller (number and sf2et, city, state, 7�p --- - --
Name of assignee or other owner or holder of mortgage
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Address of assignee (number and street, city, state, ZIP code)
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Does �pplicant own property in any other If yes, what county? V en requesled on
county in Indiana? N�vNC��y �v� w��ern yea(?� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20� 20 0 9 20 20 20 20 20
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Signature County Auditor Date
� We certify under the penalty of perjury thal the above and foregoing information is true and corced and that the applicants was / were
e,resident of Indiana and owner of the aforementioned property on March 1, 20
Si n re (owners full name) Person authorized by duly executed Power of Attomey
� �_ '�����.�.�¢� or by IC 6-1.1-12-.07
Full resident address of applipnt Address of authorized person
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