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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
S� / Stata Fortn 43709 (RS / 4-03)
�.� PrescnDed by Depanment of loral Govemment Finance �,
INSTRUCTIONS: rFi�Mark
To 6e filed in person or by mail with the CountyAuditor o/the county where the property is loca� ��
Filing Dafes: 1) Real Property: Dunng the 72 months belore May 11 oI ihe year the deduction is7� be troe�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the ye r d duc ' to be effective.
See reverse side /or additional instn�ctions and qualifrcatrons. ��� � 1 ��
or
on reverse
GIBSON
Taxing Distri� �\J�' D I Key number / legal description Record number O� _
/� [� ���Q –(� Page number / �///
llE� 7 '�'(O
As sed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, cunent year March 1, cu ent ear owner? ❑ Yes ❑ No
�
I( no, what is his / her exact share of interest? If owned with someone other Nan spouse, indicate with whom.
If name on record is different ihan that
�—��e of mortgagee or contrect seller ��
Address of mortgagee or contract seller (nu er and sfreet, city, state, 21P
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street.
Does applicant ovm property in any
countyinlndiana?
Deduction approved in the amount of:
state,
If yes, what couniy? � What Taxing District?
COUNTY AUDITOR
�����/�ir' � • . �i
� �' i � I P
Signature County Auditor
Is the property in question:
❑ Real Property p Mobile Home (IC E1.1-i
�3- ��� �
�d on
, _._.,���n�year?LJYes�No
r � i �6
Date
20
certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was I were
lent of Indiana_and own�rpf thg aforementioned property on March 1, 20
or by IC 6-1.1-12-.07
� Address ofauthorized person
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