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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709 (R6/5-06)
Plesoibed by Oepartment of Local Govemment Finance
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INSTRUCTIONS: 4 File Mark
To be filed in person or 6y mail with the County Audito� o( fhe county where the p�ope�,�� l�ate�C��
Filing Dates: 1) Rea/ P�operty: Du�ng the 12 months before ,lune il o/ the year the deduction is to b�i e��ffecUve.
2) Mobile Homes assessed under lC 6-1.1-7: Between January 15 and Ma�b�'_q(t�.D€�'r the deductlon is to be effective.
See �everse side for additional instructions and qua/�cations. G�BSON CO N1Y A ��jOR
Applicant (ownerorcontract uyer- se 2strictions on reverse side)
Taxing Distrid Key numb / legal description Record number O
/ � ^'O� ��JM �� 'O Page number � �
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Assessed value of real property as of MoAgage / Contrad in ebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, wrrent year owne(? ❑ Yes ❑ No
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If no, what is his / her exad share of interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is diHerent than that of applicant, indicate beloi
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e of mortgagee or con act •eller I�
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Address of mortgagee or conVact seller umber and street, aty,i ,
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Name of assignee or other owner or holder of mortgage ��Q �— �/ / /
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Address of assignee (number and street, city, state, ZIP code) 1 ���J� � J�� �
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Dces applipnt own property in any other If yes, what county? �� L� � U U �quested on
county in Indiana? d �� �' �] Yes❑ No
COUI
Deduction approved in the amount of:
20�� 20 0 20 20 20 20 20
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Signature County Auditor Date
e certify under the penalty of perjury that the above and foregoing information is true and corred and that ihe applicants was / were
sident of Indiana and owner oi the aforementioned property on March 1, 20
Signature (owners (ull name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
ul resident address of app i t Address of authorized person
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