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i i� �; STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�i, �;; FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�. .. N_ - i' State Fortn 43709 (R6 / 5-06) . . .
� Presai6ed by Departmeni of Local Gwemment Fi�nce �
INSTRUCTIONS: O C T 1 J F[�U I a�`
To be filed in person or by mail with fhe CountyAuditor o! the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months befoie ,lune I7 0/ fhe year the deduction is to be eflective.
� 2J Mobile Homes assessed unde� lC 6-1.1-7: Befween January 15 and March 2 of the yea�,��s to be eflective.
See reverse side fo� additional instructions and qualifications. GIBSON COUNTY AUDITOR
App� (owner or contract buyer- see restricti s on reverse side)
Taxing Distrid Key number / legal description Record number �� � 7
���� , a�-� �- ( �{ - / OI - OOo/. �ci %. Page number / � � Q
lfl / .. i
Assessed value of real properfy as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitabte
March 1, currenl year March 1, cunent year owneR ❑ Yes ❑ No
l �6,OD �� •�- -
16no, what is his / her exad share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is diiferent than that of applicanl, indicate below: Is the property in question:
- - -� - — --- - 61.1-�
me of mort ee or conirad selier
Dra���er NO a..°•° �.- (O• S l9
Address of moRg ee or contrad seller (number and street, ciry, state, ZIP
.. .... ....
Card NO. ..........
Name of assignee or other owner or holder of mortgage .
Address of assignee (numberand stieet, city, state, ZIP code)
Does appliqnt own property in any olher If yes, what county? What Taxing Distrid? Has this dedudion been requesled on
county in Indiana? property for curtent yea(I � Yes ❑ No
COUNTY AUDITOR
Dedudion approved in the amount of:
20� 20 � 20 20 20 20 20
P P
Signature County Auditor Date
/� We certiy under the penalty of perjury that the above and foregoing information is true and corred and lhal lhe applicants was / were
��resident of Indiana and owner of the aforementioned property on March 1, 20
Signature owners full name) Person authorized by duty executed Power of Attomey
Q�`�� �' ����J or by IC 6-1.1-12-.07
resident address of applicant Address of aulhorized erson
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