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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�- ; FOR DEDUCTION FROM ASSESSED VALUATION
S J State Form 43709 (Ra / f 0-0t)
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� Presaibed 6y DepaNrent ot Local Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor ol the county whe2 the propeRy is locarea. ❑c
Filing Dates: 1) Real Property: During the 12 months belore May 11 oJ the year the deduction is l0 6e effecu�L � [�
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 31 of fhe year the deducUon��l�be eflecfive.
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See reverse side (or additional instructions and quali(caGons. J� � n n
Applicant (owner
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Assessed alue of real property
March 1, current year
If no, whai is his / her exact share of interest?
GIBSON Ci�!ir.� •,�.,
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Key number / legal description U Record number O 1
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Tyn / iy,� D\ Page number �Q
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Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March}.(current year owneR ❑ Yes ❑ No
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I( owned wilh someone other than spouse, indicate with whom.
name on record is different than that of applicant, indicate below:
of mortgagee or contrad seller
Address of mortgagee or contract seller (number
Name of assignee or other owner or holder of mortgage
(number and street, city, state,
Dces applipnt own property in arry
county in Indiana?
approved in the amounf of:
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p7A�5d
Signature
aty. state, ZIP
It yes, what county? � What Taxing Distrid?
COUNTY AUDITOR
20 Q? 20 20
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County Auditor
❑ Real Property ❑ Mobile Home (IC 61.
Has this deduction been requested on'
property for current yea�? 0 Yes ❑ No
20 � I 20
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We certify under the penalty of perjury lhat lhe above and foregoing infortnation is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
�nature rs �ame Person authorized by duly executed Power of Attomey
� � or by IC 6-1.1-12-.07
11 residen ddress of applpica� Address of authorized person
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