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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S J State Fwm 43709 (RS / 4-03)
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Prescri�ed by Department of Loral Govemment Finance
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INSTRUCTIONS: �1
To be �led in person or 6y mail with the CountyAUditor o1 the county where [he property is /ocated. � U L 1 ��U��a�
Filing Dates: 1J Real Property: During the 12 months before 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 Ma�ch 2 0/ tbe year the deducUon is to 6e ellective.
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See reverse side Ior additional instnictions and quali�cations. U
GIBSCN COU�TY FUDITOR
2strictions a� rever�e side)
Distrid
Assessed value ofrealproperry as of
March 1, current year
oo, what is his / her exact share of interest?
Key numb legal description Record number
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i /�O�—bo � � � _O � Page number � � /
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MoAgage / Contrad indebtedness unpaid as of Is the applicant lhe sole legal or equitable
March 1, current year owneR ❑ Yes ❑ No
I owned wi someone other than spouse, indicate with whom.
If name on record is different ihan that of applicant, indicate below:
�me of mortgagee or contrad seller �
\J
Address of mortgagee or contred seller (number and street,
Name of assignee or other
Addn
Does
coum
Drawer NO.�.�v.•�•�•�3
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Card \O . ...: .....::..........
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Deducfion approved in fhe amount of:
zo O 1 I ze
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Signawre
de)
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state, ZIP
What Taxing Distrid?
COUNTY AUDITOR
J'� zo � zo --�
P P
_ County Auditor
0 (, • 6 053
� property in quesl
❑ Real Properiy ❑ Mobile Home QC 61.1-�
Has lhis deduclion been requested on
property for wrrent year? � Yes ❑ No
�
Date
20
We ce�tify under Ihe penalty of perjur� tha� the above and foreaoina information is Wr and correct and that the applicants was / were
!esioent of Indiana and owner of th? aforementioned property on March 1, 20
ir
Person authnnzed by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authonzed person