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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)
� Prescribed by Department ot Local Govemment Finance
INSTRUCTIONS: ��� ''7IJ File Mark –j-- ��
. To be �led in person or by mail with the County Auditor of the county where the property is located. � � y � t) ;)
Filing Dates: 1) Real Property: Dunng the 12 months before May 11 0/ the year fhe deduction is to be�effectivel�••� �Ly
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o/the year lhe deduction is to be effective.
See 2verse side for additional instructions and aualifications. N � � � V 2003
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P.pplicant (owner or nt ct buyer - see resMctio on reverse side 1''-- "/'" ""'
(� � GIBSON COUtfTY AU^ITOft
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Taxing District Key number / legal description Record number Q
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� DD� - ��a yD -oo Page number (� ,�, �
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Assessed value of real pro erty as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owner? ❑ Yes ❑ No
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It no, what is his / her exact share of interest? If owned with someone other than spouse, indicate wiih whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC 6�1.1-7)
�*�e of mortgagee or contract seller � C �
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Address of moRgagee or contract seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street, ciry, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has lhis deduction been requested on
county in Indiana? property for current year? � Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
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Signature County Auditor Date
� We certify under the penalty of perjury that the above and foregoing infortnation is true and correct and that the applicants was I were
asident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owner's full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full resident address of applicant Address of authorized person