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�`� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION
`'� • State Fwm 43709 (R6l 5-OG)
��• Presaibed by Department af Loml Gwemment Finance
wsrRUCnoNS:
To be filed in person or 6y mail with fhe County Auditor of fhe county where the property is located. �R �. 0 Zp08
Filing Dates: 1J Real Property: During the 12 months before ,lune Il of the year fhe deduction is to b��H6ctive.
2) Mobile Nomes assessed under IC 6-1.1-7: Between January 15 and March 2 of fhe yeal,the ded��is to be effective.
See reverse side for additional instrucfions and qualifrcations. 0/��
GIBSON COUNTY AUDI70R
Appti t(owne�or ntract buyer- see restrictions on reverse side)
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Taxing Distrid Key number / legal description Record number �O O/
C� �6 -i3 - a o - aoo— �/•
Page number
soy-ooy (`p07 �—
Assessed value of real properfy as of Mortgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, cunent year owneR ❑ Yes ❑ No
7D Oo0
If no, what is his / her exact share of interesl? If owned with someone other than spouse, indicate wilh whom.
s
03-�o9`I
If name on record is different than ihat of applicant, indicate below: Is the property in question:
❑ Real ProDe1N- .I�I nn.�.�e u....._ �; Cr1.1-�
e of mortgagee or contrad seller
u � � �7�
T• C . Dra��•er NO•� • /.:.
Address of mortgagee or conVact seller (number and stieet, city, state, ZIP
Name ot assignee or other owner or holder of mortgage ' CaCd � �••••"
................
Address of assignee (numberand st�eet, city, state, ZIP code)
Does applipnt own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for curtent year? � Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 _Q� 20 0� 20 / 20 20 20 20
P P ► /�
Signature County Auditor Date
e certify under ihe penalty ot perjury that the above and foregoing infortnation is true and corred and that lhe applicants was / were
sident of Indiana and owner of lhe aforementioned property on March 1, 20
Sign r(owne� /ull name) Person authorized by duly executed Power of Attomey
n`" �,� or by IC 6-1.1-12-.07
F II resident address of applicant Address of authorized person
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