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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (RS / 4-03)
Prescnbed by Department of Loc�al Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor o/ the counly where the property is located. Q � T 1 4 2��3
Filing Dates: 1) Real Property: During the 12 months before May 11 of fhe year the deduction is to be e/fective.
2) Mo6ile Homes assessed under !C 6-1J-7: Between January 15 and Ma�cA 2 0/ the yea 'tAe/�is fo' be effectiv
See reverse side for additional instructions and qualifications.
GIBSON COU TY AUDITOR
Applicant (ownerorcon uyer- see restrictions o� s e) n
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Taxing Di trict Key number / legal descri n Record number /p �
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^ , "_ _ O � � Q� � ` ��� Q U Page number � � �
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Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, current year owneR ❑ Yes ❑ No
O�Q 0
If no, whal is his / her exact share of interest? If owned with someone other than spouse, indicale with whom.
If name on record is different than that of applicant, indicate below: is the property in question:
❑ Real Properry ❑ Mobile Home pC 61.1-�
�ame of moAgagee or wntract seller
Address of mortgagee or conVacl seller (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other if yes, what wunty? What Taxing Dislrid? Has lhis deduction been requested on
county in Indiana? property for current year? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 O 20 20 20 �Q `� 20 �� 20 � 20
�P � Q P P
Signature County Auditor Date
�i/ We certify under the penalry of peryury that the above and foregoing information is irue and corred and that the applicants was / were
resident of Indiana and owner of lhe aforementioned property on March 1, 20
Signature (owners /ull name) Person authorized by duly executed Power of Attorney
r r b IC 6-1.1-12-.07
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ull resident address of applica Address of authorized person
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