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e✓""V` 4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
e±� ` : FOR DEDUCTION FROM ASSESSED VALUATION Count Township Year
'{� „y Slate Pofm 43709 (R4 ! 70-07)
� Prescribed by Depanment of Lotal Govemment Finan[e
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor of the county where the propeRy is located. N 0 � 1� 2�04
Filing Dates: 1) Real Property: During the 12 months be%re May 77 0/ the year fhe deduction is to be effective.
2J Mobile Homes assessed unde� IC 6-1.1-7: Behveen January ] 5 and March 31 0l t year the d u' n is to e e ctive.
See reverse side /or addifional instructions and qualificalions.
GIBSON COU Y AUDITOR
Applicant (owner or contract buye� - see
n r � , _ � n
Taxing
�I Pu�'aKa 7'u/
Assessed value of real properiy as of
March t, current year
If no, what is his / her exact share of
on reverse s�ne)
Key number / legal description
�
006-00� 77 —o D
Mortgage / Contrect indebtedness unpaid as
March 1, current year
� y
name on record is different than that of applicant,
moAgagee or coniraU seller
o;
Name of
Record number
Page number '
Is the applicant the le legal or equitat
owner? es ❑ No
00 � �
If owned wiih someone other than spouse, indicate with whom.
V e`( v�"
A�.�
or contract seller (number and slreet, city, state, ZIP
or olher owner or holder of mortgage �
assignee (numberandstreet, city, slate, ZlPcode)
�s cne propeny in quesnon:
❑ Real Property ❑ Mobile Home QC 67.7
O� -36 a.a
Does applicant own property in any other I If yes, what counry? I What Taxing District? Has this deduction been requested or
county in Indiana7 property for curreni year?�] Yes� N
ueoucuon approvea m tne amouni oi:
20 O� 20
�
Signature _
COUNTY AUDITOR
20 ��� 20 � 20
� P
County Auditor
20
Date
20
I/ We certify under the penalty ot perjury that the above and foregoing information is true and correct and that the applicants was / were
a resident ot Indiana and owner of the aforementioned property on March 1, 20
Signature (owners Iull name)
� � C^ ��
Full resideni address of applicant
� - — ' .
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Address of authorized person