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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
= FOR DEDUCTION FROM ASSESSED VA�UATION Coun Township Year
1 / State Fortn 43709 (RS / 4-03)
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� PresaiEed by Department of Local Govemment Finance � 1 '' ;� � 1,'
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INSTRUCTIONS: J R�il �Ma�004
To be filed in person or by mail with the CountyAUditor of the county wheie the property is located.
Filing Oates: 1J Real Property: During the 12 mon[hs be%re May 11 0/ the year the deduction is to be effective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the yeai IA_, _ e deduc(�� s��t� bµe eHective�
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See reverse side for additional instructions and qualifications. /° GIBSON COUi��T Y titlDITOft .
contracf buyer-
side)
i axmg uistna ////� Key number / legal description Record number O
����,t. U// 1 V �� Q_�Iy JZ J��_� Page number /�
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or
March 1, current year March 1, current year owne(? ❑ Yes ❑ No
Ii no, what is his / her exact share of interest?
If name on record is different lhan ihat
indicate below:
U�d I
If owned with someone other than spouse, indicate wilh whom.
�me of mortgagee or contred seller �/�
Address ot mortgagee or contract seller (nu er and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, stafe, ZIP code)
Does applicant own property in any other I If yes, what county? I What
County in Indiana?
Deduction approved in the amount of:
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Signature
�
COUNTY AUDITOR
20 � 20 _Q�
y P
Caunty Auditor
c+/ �E
Is lhe pr
❑ Real
G�o -Cr 3
� Mobile Home (IC 61.
Dra�r�er NO ...................
Card NO. ..4!.�,-„�,�,,���
�"""' equested on
❑ Yes � No
20 �� 20
P
Date
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/ We certity under the penalty of peryury lhat the above and foregoing infortnation is true and corred and that the applicants was / were
�resident of Indiana and owner of the aforementioned property on March 1, 20
j_
Person authorized by duly executed Power of
or by IC 6-1.1-12-.07
of authorized person