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°`N"„ STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
�° : FOR DEDUCTION FROM ASSESSED VALUATION .
t y� � State Fortn 43709 (R3 / 10.00)
Prescribed by Siate Board of Ta<Cortunissioners
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InsVuctions for filing:
To be filed in person or by mail with the County Auditor oi the county where lhe property is
located during lhe 12 months before May 11 of the year the dedudion is to be effective. See
reverse sfde for additional instrucfions and qualifications.
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GIBSON COIJNTY AUDITOR
Applicant (own contract buyer - ee restriction n reverse side)
Tauing District Key number / legal d ription Record number O 1
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Page number
Assessed value of reai property as ot Mortgage / Contract indebtedness unpaid as of Is the applicant t e sole legal or equitable
March 1, current year March 1, current year owner? ❑ Yes ❑ No
V�/v
If no, what is his ! her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicafe below:
N e of mortgagee or contract seller �
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Address of mortgagee or contract seller (number and stieef, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and sheet, city, state, ZIP code)
Does applicant own reai property in any If yes, what county? What Taxing District? Has this�deduction been requested on
other county in Indiana? property for current year? � Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
zo � zo O zo � Zo �,� 20 �� zo 0 zo �
�S � ¢� P P
Signature �99 County Auditor Date
I/ We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
ident of Indiana and owner of the aforementioned property on March 1, 20
5.,.�a r(owners full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Fuli Fesident address ppli nt Address of authorized person
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