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�ei "� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
'n'�': FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
��' State Fartn 43709 (R6 / 5-061 . , ' . • � . .
� Prescribed by Oepertment of Lonl Gwemment Finance
INSTRUCTIONS: NO� �i���rk
To be filed in person or by mail with the CountyAuditor of the county where the property is located.
Filing Dates: 1J Real Property: Dunng the 12 months 6efo2 ,lune 11 of the year the deduction is to be effe¢t�����
� 2J Mobile Homes assessed under lC 6-1.1-7: Between January 15 and March 2 0l the yeari/ � to be effective.
See reverse side for additional instnictions and qualifications. GIBSON COUNTY AUDITOR
Applicant (owner or conhact buyer= see restddions on reverse side)
L �S " -�
Taxing Distrid Key numbe leg scription Record number
g� � ^ �� �
� a�O —� a� O�O ' Page number 3
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant th
March 1, current year March 1, wrrent year owne(? �
If no, what is his / her exacl share of interest?
If name on record is different than that of applicant, indicate below:
�me of mortgagee or contrad seller
of
of
or conVad seller (number and street,'city,
or other owner or holder of mortgage
Atltlress oi assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county?
county in Indiana?
ueaucnon approved in the amounf
20
Signature
20
ZIP
sole legal or equitable
es ❑ No
with someone other than spouse, indicate with whom.
� Mobile Hame QC Cr1.1-�
Dra«�er n'0..0.:� � 3 2
What Taxing Distrid?
Card NO. .......�
COUNTY AUDITOR
20 20 20
County Auditor
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
�nature (now'ners (ull name) Person authorized by duly execuled Power of Attomey
A S�/,�, ���� or by IC 6-1.1-12-.07
�w«.
resident a dress of applicant Address of authorized person
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