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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709 (Rd / 10-01)
PrescriDed by Depariment of Local Govemment Finance
INSTRUCTIONS:
To be (led in person or by mail with fhe County Auditor o( the county where the property is located. �.q �Y 2 2��2
Filing Dates: 1) Real Prope�ty: During the 12 months 6e%re May 11 0/ the year the deduction is to be �bechve.
2) Mo6ile Homes assessed under IC 6-1.1-7: Behveen January 15 and March 31 0/ he year the ed�ion is be Nective.
See ieverse side for additional instructions and qualifications.
GIBSON COU� ?Y FUD�7�R
Applicant (owne or nt ct buy r- see restric ns on rever�.�jde) �
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Taxing Distrid Key number / legal description Record number
Q�' I _Q '� Page number � Q
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Asse ed value of real property as of Mortgage / Contrect indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, wrtent year March 1, current year / O � x D owneR ❑ Yes ❑ No
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If no, what is his / her exact share of interest? If owned with someone other lhan spouse, indicate with whom.
I( name on record is different than ihat of applicant, indicate below: Is the property in quesfion:
� Real Properly ❑ Mobile Home pC 61.1-�
�e of mortgagee or contrad seller � I
1 Address of mortgagee or conVad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street, city, stafe, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for wrtent yea(?� Yes� No
COUNTY AUDITOR
Deducfion approved in the amounf of:
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Sign ure64 County Auditor Date
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We certify under the penalty of perjury that the above and foregoing infortnation is true and correcf and lhat the applicants was / were
.sident of Indiana and owner of the aforementioned property on March 1, 20
i at e wners /ull name) ,� person authorized by duly executed Power of Attomey
� � or by IC 6-1.1-12-.07
Ful esident addre of applicant Address of authorized person
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