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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Sfate Fortn 43709 (RS / 4-03) .
Prescribcd by DepaRmem ol Loral Guvemment Finance
INSTRUCTIONS:
To be filed in person or 6y mail with the County Auditor of the county where the property is located. r�R 1 5 2005
Filing Dates: 1) Real PropeRy: Dunng the 72 months 6efore May 11 of the year the deduction is ro 6e eN� de
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is to be effective.
See reverse side Ior additional instructions and qualifrcations. �
GIBSO�COUNTY AUDITOR
(owner or contra�f buyer - see restriction�,qn reverse side)
� aui uistnct 1 Key number / legal description Record number
QO( ��rn �'� Pagenumber � (
io �d
Assessed value of real property s of Mortgage / ContraU indebtedness unpaid as of Is ihe applicant the sole legal or
March 1, wrrent year March 1, current year � owner? ❑ Yes ❑ No
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If no, what is his / her exaci share of interest?
If name on record is different than that of applicant, indicate below:
mortgagee e/ contract seiler
Address of mortgagee or contrac! seller (number and st2et, c
Name of assignee or other owner or holder of mortgage
(numberand street, city, sfate, ZIP
If owned with someone other than spouse, indicate with whom.
❑ Real Property ❑ Mobile Home QC 61.1-�
Does applicant own property in any other If yes, what county?
county in Indiana?
Deduclion approved in the amounf of:
20
Signature
20 Q] � I 20 O�
P �
CO
20 , 1u
P
County Auditor
20
Date
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on
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= �� =
We certify under the penalty of perjury that the above and foregoing information is true and-corred and that the applicants was / were
;esident of Indiana and owner of the aforementioned property on March 1, 20
full
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person