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STATEAAENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
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1� / State Form 43709 (RS / 4-03) �
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� 1, Presaibed by Departmem ol Lacal Govemmem Finance
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INSTRUCTIONS: � � File �r �
To be fifed in person or by mail with the County Auditor ol the county where the property is located. �'�
Filing Dates: i) Real Property: During the 12 months 6efore May 11 of the year the deduction is to be e ective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year the�c�uc�� is� effective.
See reverse side lor additional instructions and qualifications. „ n
Applicant (owner or contract
Assessed value of rea
March 1, current year
Key number / legal description
GIBSON
Record number j�
V
:' AUDiTOR
�. Page number Q
�
� Oa / �-00 i
of Mortgage ! Contrad indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, current year owner? ❑ Yes ❑ No
S�S� Oo 0
If no, what is his / her exact share of inlerest?
If name on record is different than thai
mortgagee or contraa seller
Address of mortgagee or contrad seller (number and street,
Name of assignee or other owner or holder of mortgage
assignee (numberand street, city, s[ate, ZIP code)
If owned wiih someone other than spouse, indicate with whom.
ZIP
s the property in question:
❑ Real Roperty ❑ Mobile Home QC 61.1-�
Does applicant own property in any olher If yes, what counry? What Taxing District? Has this dedudion been requesled on
county in Indiana? property for current yeaR � Yes❑ No
Deduction approved in fhe amount of:
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COUNTY AUDITOR
20 � � 20 d �
�P �
County Auditor
20 �� 20 �. 20
� P
Date
We certify under the penalty of perjury that the above and foregoing information is true and correct and that lhe applicants was / were
�esidenl of Indiana and owner of the aforementioned property on March 1, 20
name)
Person authorized by
or by IC 6-1.1-12-.07
executed Power ot Attomey
address of applicant _ , �Address of authorized person