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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (R5 / 4-03)
PrasaiEed Ey Department of Local Guvemment Finance
Coun Township Year
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INSTRUCTIONS: �' � ��''� � �l ile Mark
To be (led in person or 6y mail with the County Auditor o/ the county wheie the property is lo�c�t�,d� �`Z0�'s
Filing Dafes: 1 J Real Property: During the 12 months belore May 11 0) the year the deductio �tb e Bective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o)the year`the deduction�is to 6e effective.
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See reverse side for additional instructions and qualifications. � �} �-v '`i���p� l
G�(iSON C IUN, .
Applicant (ownerorcontracf buyer- see restrictions on revers side�
Taxing Distrid Key number / legal desaiption Record n ber ,!'��
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��> _ Q' n � /� � / C/�.� Page number �
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Assessed value oi real property as of Mortgage / Contrad indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March t, curtent year March 1, cunent year owneR ❑ Yes ❑ No
If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate wilh whom.
If name on record is different than that of applicant, indicate below: Is lhe property in question:
,� � • ❑ Real Propsiy ❑ Moble Hm�e QC 61.1-�
�me of mortgagee or contrad seiler
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Address of mortgagee or conVad seller (n -- --
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Name of assignee or other owner or holde: �/}�1"v" "_''
y
Address of assignee (num6erand street, c ��.Q.L�
Does applicant own property in any other If yes, wnac cuun�y : ., ....� _.. . Has this deduction been requested on
county in Indiana? •� property for curtent year? � YesO No
COUNTY AUDITOR
Deduction approved in the amount of:
20 p� 201L 20 /� �% 20 � 20 � 20 20
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Signature County Auditor Date
�/ We certify under the penalty of perjury that the above and foregoing infortnation is true and corced and ihat the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1. 20
'gnature (owners full name) Person authorized by duly executed Power of Attomey
�� , or by IC 6-1.1-12-.07
u resident address of ap cant Address of authorized person
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