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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES�
FOR DEDUCTION FROM ASSESSED VALUATION
State Fom: 43709 (RS / 4-03)
Prescnoetl Dy Depanment of Local Govemment Finance
INSTRUCTIONS: . �
7o be filed in person or by mail with the County Auditor of the county where the property is located.(� 7 2��5
Filing Dates: 1),Real Property: During the 12 months befo2 May 11 o/the year the deduction is to tlE��e�ive.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 olthe �y—eya,�, the deduction is to be eNective.
See reverse side for additional �instructions and qualifrcations. l/ ��cG �i:�O,
� GIBSON COUNTY AUDITOR
or confract �ver- s� restnctions on reverse side)
Taxing
Assessed value of real property as of
March 1, current year
If no, what is his / her exact share of inierest?
Key number / legal description Record number ��
�r I�� I� ' O Page number �� p2
� 6J
Mort9age / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current ye owner? ❑ Yes ❑ No
�
If o ned with someone other than spouse, indicate with whom.
name on record is differentthan that of applicant, indicate below:
ame of mortgagee or conlraIX seller � , �
Address of moAgagee or contreG seJ�-'� �
/ _ (� .°.g•'''.
/ � ••J
Name of assignee�� �Q •'
�Ca��e<
Address of assi5 ,,.•
Ca�a�o � .
Does applicant own ^,`�Q ' ,�s, what counry?
county in Indiana? �\.. 1� � I
\Y
approved in the amount of:
20 �� 20 ��
1 Y
Signature
state, ZIP
What Taxing District?
COUNTY AUDITOR
20 � 20 20
County Auditor
property in question:
❑ Real Properiy ❑ Moble Home (IC Cr1.
Has this deduclion been requested on
property for current year? � Yes � No
Ti7
20
�/ We certify under the penalty of pe�jury that the above and foregoing information is true and correIX and that ihe applicants was / were
a resident of Indiana and owner of the aforementioned property on March 1, 20 ,�
of
S-f , T-� , �ru,�� �
— V7.
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07 �
of authorized person