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�ai ;� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
(+' � FOR DEDUCTION FROM ASSESSED VALUATION �
�j Siate Fortn 43709 (R6 / 5-06) � � � �
� Presvibed by Department of Lonl Govemrtrent Firiarxe
INSTRUCTIONS:
To be (iled in pe�son or by mail with the County Audito� o( lhe county where the p�operty is locafed. .
Filing Dates: 1 J Real Property: During the 12 months before ,lune 11 of the year the deduction is to be e/%
�IYQ 1 �, 700�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o(the yea� t e deduc �on �s o 6e effective.
See �everse side for additional instructions and quali(rcations. `�� ��,
GIBSON
(ownerorcontract buyer- see 2strictions on reDverse side)
�Q/n/X-F.. �° Cli�`iC,t�nn,
Taxir/§ Distrid Key number / legal desuiption Record number
� aG� -r 9- 3 �- 3 oi - cr�. aoo �
Page number
! S- o0 o'Z S'�j b
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant lhe sole legal or equitable
March 1, current year March 1, curtent year owneR ' � Yes � No �
Sa, 00 v
If no, what is his / her exact share of interest? If owned with someone other lhan spouse; indicate wilh whom.
If name on rewrd is different than that of applicant, indicate below:
�me of moRgagee or contract seller � n `
i i �'�-�
Address of mortgagee or contrad seller (number and st2et, city,
Name of assignee or other owner or holder of mortgage
of assignee (number and st2et, city, state, ZIP
Does applicant own property in any other I If yes, what counry?
wunty in Indiana?
Deduction approved in fhe amount of:
20 �_ I 20 � � I 20
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Signature
COUNI
r�
County Audito
Is the property in
❑ Real Property
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ZIP
❑ Mobile Hane pC 61.1-�
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sa, oa d. � � �P ��f �, �
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�� iested on
Yes ❑ No
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We certify under the penalty of perjury that the above and foregoing intortnauon-o,,,.,,-o..___ _ Nas / were
�esident of Indiana and owner of the aforementioned property on March 7, 20 --- —
n ure (owners /ull name) Person authorized by duly executed Power of Attomey
-�,��� . �. �j )��n or by IC 6-1.1-12-.07
authorized person