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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
S � � State Form 43709 (R5/4-03�
� PrescriDed by Depanment of Laal Govemment Finance ���� �7� �t.. �
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INSTRUCTIONS: File Mark
To 6e filed in person or by mail with the Counry Auditor of [he county where the property is located. D E C ��, a Z�03
Filing Dates: i) Real Property: During the 12 montAs before May 11 of the year the deduction is to be eflective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the yea'r the deduUion7'is to be effective.
See reverse side for additional instructions and quali�cations. ��tJy
GIBSOi'd COUrITY AU�JITOR
Taxing
Key number / legal description
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Record number
�
number /G � �
Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, cunent year March 1, current year owner? ❑ Yes � No
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If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
IT name on record is different than that of applicant, indicate below: Is the property in question:
of mortgagee or contract seller
Address of mortgagee or contract seller (number and street,
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 county?
county in Indiana?
Deduction approved in the amount of:
20 20�_ 20
P
Signature
state.
What Taxing I
COUNTY AUDITOR
r'I1��iZi7
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County Auditor
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❑ Real Properry ❑ Mobile Home QC 61.
Drawer NO. e �•�..�. •°•�'' �.y
CardNO . ..................... _
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20
20
I/ We certify under the penalty of perjury that the above and foregoing infortnation is true and correct and that the applicants was I were
\esident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
address of applicant „. �Address of authorized person