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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
��w / State Fortn 43709 (RS / 4-03)
Presaibed by Deparimem ot local Govemment Finance �� ` �'
�INSTRUCTIONS: �; � �f 1 File �
To 6e filed in person or 6y mail with the CountyAuditor of the county where the property is located.
� Fding Dates: �) Real Property: During the 12 months before May 11 of fhe year fhe deduction is to�e elfecfive. � /�
) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the yearlthe:deduction•is,to,be e�+ctive.
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See reverse side for additional inshuctions and qual�cations. �d GIBSOid COUhTY AUDITOR �
contrect buyer
Taxing District
Assessed value of real property as of
March 1, current year
no, what is his / her exact share of interest?
on reverse side)
Key number / legal description
number
Vv U ^
Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owne� �s ❑ No
�
� If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below:
�e of moRgagee or contract seiler
�Q�1� �sn �, `1� ,,.� . I
Address of mortgag or contract seller (number and street, city, state,
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, Z/l
Does applicant own property in any other If yes, what �
county in Indiana?
Deduction approved in lhe amouni of:
Name
property in queslion:
Property ❑ Mobile Home (IC E1.
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C�'"-.c�- J���� ,�
Document o�do3_ j g-�s
Date � ,3� _ p 3
Bank �NPJ
COUNTY AUDITOR
20 Q� I 20 �_ I 20 C I tJ I 20
T
Counly Auditor
20 �� I 20
Date
20
m
No
certify under the penalty of perjury that the above and foregoing infortnation is true and correct and that the applicants was I were
ent of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
nt Address of authorized person
�19 P,,:, ���--��, r �