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���g STATEMENT MORTGAG OR CONTRACTINDEBTEDNESS
's' : FOR DEDUC SSED VALUATION Coun 7ownship Year
/ State Fwm 43709 (R6 / 5-061
� Presaibed by Depariment of Local Gwemment Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor o/ fhe county where the property is located. MQR 2 6 ZQQ$
Filing Dafes: 1) Real Prope�ty: DuAng fhe 12 months befo2 ,lune Il of the year the deduction is to be el%ctive.
2J Mobile Homes assessed under IC 6-7. 7-7: Between January 15 and March 2 of the yeaFide,�u '�is to be e/fective.
a ��
See �everse side for additional instructions and qualifications. GIBSON COUNTY AUDITOR
Applicant
Taxing Distrid
buyer- see 2stricti�s on r�verse side)
�.�-.i—��-�u
Assessed value of real property as of
March t, current year
If no, what is his / her exacl share of interesl?
If name
mortgagee
Key number / legal description Record number �� �
Page number
). �-O �
Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrrent year �9�� ownef? ❑ Yes ❑ No
� �
If owned with someone other than spouse, indicate with whom.
�that o applicant, indicate
i
seller
Address of mortgagee or contract seller (number
city,
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st�eet, city, state, ZIP code)
Dces applipnt own property in any
county in Indiana?
Dedudion approved in the amount of:
20
Signature
20
�
If yes, what county?
e, ZIP
0
What Tax
COUNTY AUDITOI �
20 20 20
County Auditor
❑ Real
❑ Modle Hane OC 61.
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Dra��'�I' �'�.�l.l.lU.....�Ci No
C� 1�' . .............
� �''�029� acd ��
20
Date
3�]
certity under the penalry oi perjury lhat the above and foregoing information is true and corred and lhat the applicants was / were
ient.ofJndiana and owner of the aforementioned property on March 1, 20
�
ue wners (ull name Person authorized by duly executed Power of Attomey
7� , �. � � � �-� . � „n .,, � Or by IC 6-1.1-12-.07
of authorized person
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