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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
4+ �M� / State Form 43709 (R5 / 4-03)
� Prescnbed by Departmenl of Loral Gcvemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the CountyAUditor of the county where the property is located. FFR �j Z�� �
Filing Dates: 1J Real Property: Dunng fhe 12 months before May 11 0/ the year the deduction is fo be eflect�e.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the deduction is to be effective.
See reverse side lor additional instructions and qualifrcations. !/c� � f�
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GIBSON COUNTY :�Up170n
Applicant (owner
Taxing Distrid
Assessed value of real property
March 1, wrrent year
I( no, what is his / her exact share
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Key er / legal escription Record number
a�-��� 03 000. osa-oo7 � �
a Page number � �
Mortgage / Conlract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owne(? ❑ Yes ❑ No
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If name on record is diHereni than that of applicanl, indicate below:
me of mortgagee or wntract seller
ot mortgagee or contracl seller (number
of assignee or other owner or holder of mortgage
Address of assignee (number and sUeet, city, state, ZIP
If owned with someone other than spouse, indicate with whom.
ZIP
Does applicant own property in any other If yes, what county? What Taxing Districl?
county in Indiana? —
�OUNTY AUDITOR
Deduction � Dra�r�er NO...�.�.�
2o Card NO. ...1g�......�..... 20
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County Auditor
20
❑ Reai
HomeQC 61.
Has this dedudion been requested on
property for current yea(?� Yes❑ No
20
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certify under the penalty of peryury that the above and foregoing information is true and corred and that the applicants was / were
!ent of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
❑uem a�re�s o� appu n[ dress of authorized person
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