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� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
°. / State Form 43709 (R5/4-03) � �
�M�
� PrescnDed by Departmem of Local Gtivemment Finance
wsrRUCrioNS: D E CF;�;��804
To 6e filed in person or by mail with fhe County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to be ective /J /�f
2) Mobile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 o/the y �te�a.e�de.
See reverse side for additional instructions and qualifications. �IBSON COU 7Y A.U��70R �
6uyer
Taxing Dislrid
�L1T /(�2��
on reverse side)
�
y number / legal description
D//- �9� �
number
number
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitabie
March 1, curtent year March 1, wrrent year � owne(? ❑ Yes ❑ No
If no, what is his / her exact share of interest? If owned with someone olher than spouse, indicate with whom.
If name on record is differeni than that of applicant, indicate below: Is the property in question:
of mortgagee or contraG seller
Address of mortgagee or wntract seller (number and
Name of assignee or other owner or holder of mortgage
J��C:��
city, stale, ZIP
of assignee (num6er and st�eet, city, state, ZIP code)
Ooes applicant own property in any other I If yes, what county? What Ta�
county in Indiana?
Deduction approved in the amount of:
20 � I 20
Signature _
�
COUNTY AUDITOR
20 �_ 20 � �1 ' 20
� �
County Auditor
❑ Real Properly ❑ Mobite Home (IC 61.1-�
Drawer NO. � �f. -..�' °? � 7
Card NO. . sted on
.................... es❑No
�
Date
20
certity under the penalty of peryury that the above and foregoing information is true and corred and thal the applicants was / were
ient of Indiana and owner of the aforementioned property on March 1, 20
(owners full name)
Person authorized by duty executed Power of Attomey
or by IC 6-1.1-12-.07
address of applipnt �Address of authorized person