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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FQR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
��• " J, Sute Form 43709 (R5 / 4-03)
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Presui�etl Dy Departmeni ot lowl Govemment Finance
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INSTRUC710NS: OCT ] � Z���eMark
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real PropeRy: During the 12 months beio2 May 11 0/ the year the deduction is to_b� ffective.
2) Mo6ile Homes assessed under IC 6-L 1-7: Between January 15 and March 2 of thg%ye O ecdetf�tion is to be effective.
See reverse side /or additional instructions and quali�cations. GIBSON COUNTY AUDI70R
(owner or contract buyer - see
7 M � w //// �
Taxing Distrid
�/G/ii
Assessed value of real property as of
March 1, ciirrent year
If no, what is his / her exact share of interest?
on reverse
Key number / legal
lJ0 � - � '�//Jr0 - �
Record number
Page number
Mortgage ! Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year owner? ❑ Yes ❑ No
Ii owned with someone other than spouse, indicate with whom.
If nzme on record is different than that of applicant, indicate below:
�3me of mortgagee or conVad seller
C� N�
Address o( moAgagee or contract seller (number and street, city, sfafe, ZIP
tJame of assignee or
Address
owner or hotder of mortgage
(number and st�eet, city, state, ZIP code)
Does applipnt own property in any other if yes, what county?
county in Indiana? �
Deduction
20 �
�
Signature
Is the property
❑ Real Properly ❑ Mobile Home QC 61.
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Drawer NO:....�•�•
wr,; Card NO. .. �,,.p�/�•��.�..,..,�.y/; q
�f �.3�i �� CTa n� "'" ❑ Yese� No
� COUNTY AUDITOR
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in the amount o(:
20 D� 20 0� 20 20
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County Auditor
20
20
certify under the penalty of perjury that the above and foregoing information is true and correct and thal the applicants was! were
ient ot Indiana and owner of the aforementioned property on March 1, 20
(owners full
resid^enet
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Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person