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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R3 / 10-00)
Prescribed Dy State Board of Tax Cortuniuioners
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Count Township Year
NOV OF�e3�}d
Instructions for filing:
To be filed in person or by mail with the County Auditor of the county where the property is
located during the 12 months before May 11 of lhe year the deduction is lo be effective. See
reverse side for additional instructions and qualifications. GIBSON COU":TY AL�DITOR
Applicant (owner er- s'ctions o verse i e) '
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Taxing Distrid ey number / legal scri ' Record n er
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Assessed value of real property as of Mortgage / Contrect indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, wrrent year owne(? ❑ Yes ❑ No
If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
t�e of mortgagee or contract seller l
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Address of mortgagee or contred seller (number and stieet, city, state, ZIP
Name of assignee or other owner or ho�der of mortgage
Address of assignee (number and sfreet, city, state, ZIP code)
Does applicant own real property in any If yes, whal counry? What Taxing District? Has this deduction been requested on
other county in Indiana? property for current yea(? L7 YesL� No
COUNTY AUDITOR
Deduction approved in the amounl of:
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ig ture County Auditor Date
���Ne certify under the penalty of perjury that the above and foregoing information is lrue and correct and thai the applicants was / were
�ident of Indiana and owner of the aforementioned property on March 1, 20
Signature ers fullname) Person authorized by duly executed Power of Attomey
' or by IC 6-1.7-12-.07
F esiden addr s of applicant Address of authorized person
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