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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�. ,«• / State Fwrt: 43709 (RS / 4�3) . . . . . � � .
�P2scri�ed by Depanment of Local Govemment Financa
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor ot the county where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 montbs be%re May 11 0/ the year the deduction is to b�9f�ectye� 2��4
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is to be eNective.
See reverse side for additional instructions and quali�cations. /�� J°V�—�-�-Y�
� Gi9S6N CCU��71' qlfD'TC3 I
i .. ��1 ,� ! _. _
(owner or
Taxing
Assessed value oi real property as of
March 1, current year � �
side)
Key number / legal description I Record number O�
� / � .� DD � J75'� Page number � � (
Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equi
March 1�urrent ye2r � owne(? ❑ Yes ❑ No
� �P������
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 lhan that of applicanl, indicate below:
of mortgagee or contrad seller
aa, ��,G
er and stre�t, city, state. ZIP
nortgage
vtate, ZIP code)
Does applicaM own property in any ofher I if yes, what counly? I�;Vhat Taxing District?
county in Indiana?
Deduction approved in the amount of:
r� I
Signature
20
COUNTY AUDITOR
20 �� 2C _o�_ 20 � �
P _� L ?
County Auditor
sthe property
❑ Reai PropeAy ❑ Modle Home QC 61.1-�
Has this deduction been requested on
property for current yea(? ❑ Yes ❑ No
20
Date
20
/ We certify under ihe penalty of perjury that the a5ove and foregoing information is true and correcl and ihat the applicants was / were
� resident of Indiana and owner of the a(oremer.tioned property on March 1, 20
of
Person aulhorized b�
or by IC 6-1.1-72-.07
of
executed Power of Attorney
person