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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�• ! State Fwm 43709 (RS / d-03)
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, �� PrescriDed oy Depanment of Local Govemment Finance
wsraucnoNS: ,1UN 1 5��Qba�
To be (iled in person or by mail with the County Auditor ot the county where the property is located.
Filrng Dates: 1) Real Property: Dunng the 72 monfhs 6efore May 11 0l the year the deduction is to be trve.
2) Mobile Homes assessed under IC 6-1.1 •7: Between January 15 and March 2 0/ the ye��e�c4�.is to be ef/ective.
See reverse side for additional instructions and qualifrcations. GIBSON COUNTY AUDITOR
� l0— 1
(owne� or contract buyer- see
�
Taxing Di
Assessed value oi real property as of
March 1, curtent year
If no, what is his ! her exact share of
-a� -'�oG c� �
'ctions on reverse side)
Key number /
r�r�� ��.o
MoRgage / Contract indebtedness
March 1, current year
If name on record is different than that of applicanl, indicate below:
of mortgagee or conlraci seller•
of
Name of assignee or
Address
YI
Record number
Page number
as of ts the applicant the sole legal or equitable
owner? �.�'gs ❑ No
�
If owned with someone other than spouse, indicate with whom.
or contract seller (number and sVeet, city, state, ZIP
owner or holder of mortgage
(numberand st2et, city, state, ZIP code)
Does applicant own property in any other I If yes, what county? I Wh;
county in Indiana? � �
Deduction approved in the amount of:
20 � L 20 �_
P
Signature
couNTV auo
20 0� 20
P
County Auditor
property in question:
al Property ❑ Mobile Home QC 61.1-�
�---
Drawer NO. a�5.......
�- ' � uested on
3�3 q
Card NO . ....:................ � vesO No
�(�'Y.D00
�a. �
20
20
Date
20
We certify under the penalty of perjury that the above and toregoing information is true and correct and lhat lhe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
name)
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
:nt�ddre/ss� oi applicant (Address of authorized person
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