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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709 (R4 / 1QOt)
PrescribeC by DeDartmenl of Local Govemment Finance
INSTRUCTIONS:
To 6e filed in person or by mail wifh the County Auditor ol the county wheie the property is located.
Filing Dates: 1) Real Property: During the 12 monfhs 6e%re May 11 0l the year the deduction is to b��%ctiv�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Ma�ch 31 the year the d
See reverse side /oradditional instructions and qualifica6ons. � �� (
Applicant
Assessed value of real property as of
March 1, current year
If no, what is his / her exact share of interest?
side)
Key number / legal description
G1Q ( -f � o/o -Oa
Mortgage / Contrad ii
March 1, wrrenl year
name on record is difterent than that of applicant,
of moRgagee or contrad seller
Address of mortgagee or conVact seller (number and street, city,
assignee or other owner or holder of mortgage
of assignee (number and street, city, sfate, ZlP code)
If
GIBSON
Record number
is to be eHective.
❑�
Page number �� �
as of Is the applicant the sole legal or equitable
owneR ❑ Yes ❑ No
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someone other than spouse, indicate with whom.
property in question:
❑ Real Prope�iy ❑ Mobile Home QC Et.1-�
Does applipnt own property in any other If yes, what county? What Taxing Distrid? Has this dedudion been requested on
counfy in Indiana? property for current year?C� Yes❑ No
20
COUNTY AUDITOR
approved in the amount of:
20 � 20 6 • 20 � �"
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County Auditor
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Date
20 �� =
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certify under the penalty of peryury thal lhe above and foregoing informalion is true and corred and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
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Full resident address of
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Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person