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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R6 / 5-06)
Presaibed by Depertment of Local Gwemment Finaixe
Coun Township Year
�NSrRUCnoNS: NOV 0 ��2�`
To be filed in pe�son o� by mail with the County Audito� ol the county where the p�operty is located.
Filing Dates: 1) Real Property: During the 12 months 6efoie ,lune Il of the year the deduction is to be eflective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o/fhe year`t�e,5�u�as�to be effective.
See reverse side for additional instruc6'ons and qual�cations. GIBSON COUNTY AUDITOR
Applicant (ow orconhact uyer- see re ri 'ons n reverse s' )
Taxing District ey n al description Record number
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Assesse vatue of real property as of Mortgage / ContreG indebtedness unpaid as of Is the applicant the sole legal or equitabte
March 1, curtent year March 1, current year owneR ❑ Yes ❑ No
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Ii no, what is his / her exact share of interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real PropeAy ❑ Mobile Horne (IC Cr1.1-�
me of mortgagee or contrad seller ��n n� �LQ .
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Address of mortgagee or wntrad seller (number and st2et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6erand street, city, state, ZlPcode)
Does applipnt own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for wrrent year?0 Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20�� 20�� 20�� 20 20 20 20
Signature County Auditor Date
�/ We certify under lhe penalty of perjury that the above and foregoing informalion is true and corred and that the applicants was / were
a resident of Indiana and owner of ihe aforementioned property on March 1, 20
Signature (owners 1 name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full resident address of plipnt Address of authorized person
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