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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
�' w� J Stata Fortn 43709 (RS / 4-03)
��.PrescriDed Cy Department ot Local Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the Counry Auditor of the county whe�e the propeRy is located. g � T Q 6 2��3
Filing Dates: 1) Real Property: During fhe 12 months before May 11 0/ the year the deduction is to 6e eHecti e.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the ye thi�n i 6e e((ective.
See raverse side for additional ins[ructions and quali�cations.
GIBSON COU TY AUDITOR
Applicant (owner or
Taxing Disirid
Assessed value of real property as
March 1, current year `
no, what is his / her exact share of interesl?
If name on record is different ihan that
of mortgagee or contraIX seller
Address of mortgagee or contracl seller
ieverse side)
Key number / legal description � Record number
O// �DDD�3 � Pagenumber
10
V_
/c
Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, cur�nt year ownef? ❑ Yes ❑ No
�� 700'U
If owned with someone other than spouse, indicate with whom.
indicate below:
and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (numberand street, city, state, ZIP code)
Does applicant own property in any other )f ves. what.r„���w2_ ._ -- �.�-� �-- =—Distnd?
county in Indiana?
DrawerNO ...................
Deduction approved in ihe am.
,
20 20 �[ �s
.. . ,.
Signature
Card NO. ..V3 .�4•�a�—
20 (`JE% � 2p��
County Auditor
20 ��
P
s the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-�
Has this deduction been requested on
property for wrrent yeaR � Yes� No
20
Date
20
certify under the penalty of perjury that the above and toregoing infortnation is true and correct and that lhe applicants was / were
lent o( 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
Ient atldress ot applic3nt Address of authorized person
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