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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709 (R6 / 5461 � ; ��
Presaibed by Depariment of Lopl Grnemment Finance
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INSTRUCTIONS: File Mark
To be filed in person or by mail with the CountyAudito� of the county where the property is located. QCT 1 5 Z���
Filing Dates: 7) Real Property: Dunng the 12 months before June i 1 0( the yea� the deduction is to be el%ctive. •
2) Mobile Homes assessed unde� IC 6-1.1-7: Between January 15 and March 2 of the year We,.�educGqp js to be effective.
See reverse side fo� additional instnictions and qual�catrons.
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GIBSON COUNTY AUDITOR
Applicant (owner or contract
side)
Key number / legal description
a G-ao -o a-�o�-c�o:
number
Pag_ e qumber �/��.,
-(X�S `7CJ
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal equitable
March 1, wrrent year March 1, current year � a OD owner7 ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is difierent than that of applicant, indicate below: Is the property in question:
� . ❑ Real Prope�iy ❑ Moble Hane pC 61.1-�
of mortgagee or contract seller
Address of mortgagee or contract seller (number and street, �, state,
of assignee or other owner or holder of mortgage
Address of assignee (numberand stieet, city, state,.ZIP
Does applicant own property in any other If yes, what ca
county in Indiana?
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0
approved in the amount of:
2�� � 20
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Coun
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fudion been requested on
current yeafJ� Yes� No
20
We certiy under lhe penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana�and owner of the aforemenlioned property on March 1, 20
Person authorized b�
or by IC 6-1.1-12-.07
ot applicant `" - '"QQ_ Address of
QN� S�C..Y� /'/GT
executed Power of Attomey
person