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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�' ✓� State Form 43709 (R5 I 4-03)
PrescnEed Oy Oepartment of Loral Govemmeni Finance
�M
INSTRUCTIONS: ����� ile ark
To be (led in �person or by mai! with the Counry Auditor o! the county where the property �at�jd.��
Filing Dates: i) Real PropeRy: Dunng the 12 months belore May 11 0/ the year the deduc n is�
. 2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and Marc 2 0( the year the dedu tion is to be effective.
See 2verse side for additional instructions and qualifications. �UN 1 3 Z�O�
(o�mer or
Ass�ssed value of real property
March 1, current year
no, what is his / her ezact share of interest?
) GIBSON GUUrv �
number / legal description Record number
� Q O age number 33� 1
Mortgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year Q� � O� owne(? ❑ Yes ❑ No
1
If owned with someone olher than spouse, indicate with whom.
If name on record is different than lhat of applicant, indicate below:
tme of mortgagee or contrad seller ^
V
Address of mortgagee or contracl seller (number and str et, city, state, ZIP
Name ,zUO j..._ �a�/ --•--�-.,..o_
�weC-A10.......... s�/37o�
Addre ,s':�.6 -or .....
— Card NO......�.,�,��/.ZOd °d
Does %1 .•........
count �� ; 1�.�_�
vL (.l.ttS/t0�+..%
Deduction
���
Signature
de)
ity? I What Taxing Distrid?
COUNTY AUDITOR
in the amount of:
20 �_ 20 �_ 20 20
� P
County Auditor
property in question:
❑ Real Property ❑ Mobile Hane (IC 61.
Has this deduction been requested on
property for current year? ❑ Yes � No
20
Date
20
We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Aftomey
or by IC 6-1.1-12-.07
authorized person
%'f h C �0�+