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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES3
FOR DEDUCTION FROM ASSESSED VALUATION
S�/ State Fwm 43709 (R5 / 4-03) .
� Pmscnbed Dy Depanment ot Lazl Gtivemment Finance
INSTRUCTIONS:
To 6e filed in person or 6y mail with the County Auditor ol the county where the property is located.
Filing Dates: 1J Real Property: During the 12 months be(ore May 11 0l the year the deduction is to 6�¢�c�,ivPi,1 Z��6
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and MarcA 2 0/ the year the deduction is to be e((ective.
See reverse side for additional instructions and quali�cations.
�°O �`P
/'1 - GIBSON COUNTY AUDITOR
Tauing Distrid
�Gl ,
� �� � �
,
A essed value of real property as of
March t, current year
If no, what is his / her exact share of interest?
on
0
Key number! legal description � Record number
��� t/O'
___����-�`� � 'J�—� Page number
Mortgage / ContreU indebtedne unpaid as of Is the applicant the sole legal or e
March 1, current�year �� /Yr� owneR � Yes ❑ No
• 9 � �.u�
"�� , �. �.
If owned with someone other than spouse, indicate with whom.
If name on record is different ihan that of applicant, indicate below:
�me of mortgagee or contract seller ^
Address of mortgagee or contrad seller (number and streef, city, state, ZIP
of assignee or other owner or holder of mortgage
of assignee (number and street, city, state, ZIP code)
Dces applicant own property in any
county in Indiana?
20
Signature
approved in the amount of:
20
If yes, what counry? I Wh�
s the property in question:
� Real Property ❑ Mobile Hane QC 61.1
Dra���er NO......,,'........... --
�/ �uested on
Card N�. Q.Sr.../.�.7� 1Yes�No
COUNTY AUC
20 � 20 20
County Auditor
�
Date
20
We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
�esident of Indiana and owner of the aforemenlioned property on March 1, 20
nalure (owners full name) Person authorized by duly executed Power of Atlomey
or by IC 6-1.1-12-.07
1 resident address of applicant Address of authorized person
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