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�ei '" ",� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�i'�'� FOR DEDUCTION FROM ASSESSED VALUATION Count Township Year
\'• State Form 43709 (R6 / 5-06) �
�•�. •-
� Resai6ed by Departmenl of Lopl Gwemment Finance �
INSTRUCTIONS: OCT 1 5 Z�QA Ma�
To be /iled in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 7) Real Property: Dunng the 12 months befo2 ,lune I1 0/ the year the deduction is to be�e,�
2) Mobile Homes assessed unde� IC 6-1.1-7: Between January 15 and March 2 of fhe year th ed c +��6e effective.
See reverse side for additional instructions and quali(icalions.
GIBSON COUNTI�
�'.
�. A
6atr� —ii i[� �[
Assessed value of real property as of
March 1, wrrent year
If no, what is his / her exact share of interest?
name on record is different than that
of mortgagee or contracl seller
Address of mortgagee or contract
c�
Key mber / legal d i
Mortgage / Contract inde
March 1, current year
��
If a
ant, indicate below:
and sfr�et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city,
Record
Page
unpaid as of Is the appliwnt the sole legal or
ownef7 ❑ Yes ❑ No
with someone other than spouse, indicate with whom.
Does applicant own property in any other � If yes, what county? What Taxing
county in Indiana?
Deduclion approved in the amount of:
20 �� 20 20
P
SignaWre
COUNN AUDITOR
20
County Auditor
20
Is lhe pi
❑ Real
O Mabile Home (IC Frt.1-
�
7���� ion
D�•a\�'CY��O...••••"'.. .• �No
/ .
CaYd��• ... • • '� —
20
Date
�
� We ceAify under the penalty of perjury that the above and foregoing infortnation is true and corred and lhal lhe applicants was / were
� residenl of Indiana and owner of the aforementioned property on March 1, 20
Signathre (o ers /ull name) person authorized by duly executed Power of Attomey
� or by IC 6-1.1-12-.07
ruu resitlent atltlress ot applic3n[ �76�qddress of authorized person
`� C�'S` g� 3 / �,P�i�.�i✓.�t/ � i
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