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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Siate Fortn 43709 (RS / 4-03)
PresrriEed by Depertment ot Local Govemment Finance
Coun Township Year
�I� E
INSTRUCTIONS: OCT ���e ��
To be �led in person or by mail with the CounryAuditor of the county where the propeRy is located.
Filing Dates: 1J Real Property: During the 12 months before May 11 of the year the deduciion is to effecfive. ///�
2) Mo6ile Homes assessed under IC 6-1.1-7: Befween January 15 and March 2 ot th�eerYhe'�ctf n is tb'tfe �/fe�tive.
See rsverse side for additional instructions and qualifications.
/ GIBSON COUN i Y�UDITOR 1
� I I I_i i� _,,,rr r,�,� <t �� ..,,-, r
or contract 6uyer -
��
Assessed value of real property as of
March 1, current year
no, what is his / her exact share of interest?
Key number / legal description // I Record number 3
/� l/ Q
/}�� — /M'!93 — dQ Page number
a<� �C�CJC� /
Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owner? ❑ Yes ❑ No
G�� I
If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: O 7 3rlT 9
7S I
�e of mortgagee or contract seller
�-� ��
Address of mortgagee or contract seller (number d street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sVeef, city, state, ZIP code)
Does applicant own property in any other If yes, what county? I What Taxing
county in Indiana?
COUNTY AUDITOR
Deduction approved in the amount of:
20� 80 �� 20 I 20 � I 20 �
�T
County Auditor
❑ Real Property ❑ Mobile Home pC E1.
mps�i�o��s e
�ps��%� S
20 �_
P
D3-�'/�I�`
�,� ��s ueaucnon been requested on
property for curcent year? � Yes ❑ No
20 O I 20
P
Date
certify under the penalty of perjury that the above and foregoing infortnation is lrue and coRect and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
Person aulhorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
applicant / �Address of authorized person