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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fortn 43709 (R5/4-03)
PrescnDeE by Depariment of Local Govemment Finance
Coun Township Year
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INSTRUCTIONS: File Mark �
To be filed in person or by mail with the County Auditor o( the county where the property is located. 5E� 2� 2�03
Filing Dates: 1) Real Property: During the 12 months 6efore May 11 of the year the deduction is to 6e�eBective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the ar the ded "cti s to b ff ive.
See reverse side (o� additional instructions and qualifrcations. J
GIBSON COU TY AUDITOR
Applicant (owner or contract buyer - see rest�ctions on reverse side)
Tauing Distrid Key number / legal description Record number
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�� O C� ^ ���^�� Pagenumber
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, current year ��—a, c�'d � owne(? �S ❑ No
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If no, what is his / her exacf share of interesl? If owned with someone other than spouse, indicate with whom.
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If name on record is different than that of applicant, indicate below: Is the roperty in question:
Rcipe�iy ❑ Mobile Home (IC Cr1.1-�
me of moAgagee or contrad seller /�
5 71 �'-e-
Addre s of mortgagee or contract seller (number and streef, city, state, ZIP
Name of assignee or other owner or holder of mortgage -- ----
DrawerNO ...................
Address of assignee (number and sVeet, city, state, ZIP code) o�_ s,��
Card NO. �
.....................
Does appiicant own property in any other If yes, what county? Wha �sted on
county in Indiana? 'es❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
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Signature � County Auditor Date
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�/ We certify under the penalty of perjury t� t ihe above and foregoing information is true and correct and that the applicants was / were
. resident of Indiana and owner of the afo�mentioned property on March 1, 20
Signature (ow ers full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
A
Ful esident address of appli nt Address of authorized person
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