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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709 (R6 / 5-06)
Presaibed by Department of Lopl Gmemment Finance
INSTRUCTIONS: � -
To be fi/ed in person or by mail with the County Auditor of the county where the property is located. � � T 1 6 ZOQ�
Filing Dates: 1) Real Property: Dunng the 12 months befo2 ,lune 11 of lhe year the deduction is to be eHective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the yea� th�d,e_ductio�s to be elfective.
See reverse side fo� additional instiuctions and quaJifications.
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GIBSON <�
COUNTV eiin��....
Applicant (owner o ract bu er- see ' i s ve e ide�
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Taxin i ri Key number / �egal desuiption Record number
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Assessed value of real property as of MoAgage / Contrad 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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Ii no, what is his / her exact share ot interest? If owned with someone other lhan spouse, indicate with whom.
If name on record is different than lhat of applicant, indicate below: Is the property in question:
❑ Real Properiy ❑ Modle Horne (IC 61.1-n
me of mortgagee or contrad seller
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Address of mortgagee or contract seiler (number and street, city, sfate, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what counry? What Taxing Distrid? Has this dedudion been requested on
county in Indiana? property for current year? � Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of: '\
20 �f 20 �_ 20 20 20 20 20
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Signature County Auditor Date
We certify under the penalty of perjury that the above and foregoing information is true and correct and lhat the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
� Sig ture (owners lul naryiP)� Person authorized by duly exewted Power ot Attomey
t� or by IC 6-1.1-12-.07
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I residenf ress of applipnt Address of authorized person �
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