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STATEMENT OF MORTGAGE OR CONTRACT INU�Eii�DtvE��
FOR DEDUCTION FROM ASSESSED VALUATION
State Farm 43709 (R6 / 5-06) � '
Presaibetl by Department of Loral Gwemment Finance
INSTRUCTIONS:
To 6e filed in person or by mail with the County Audito� ot the county whe�e fhe p�operty is locatefj� 9 �r,
Filing Dates: 1J Real Property: DuAng the 12 months before ,lune � 1 0/ the year the deduc6on is to be ellec'Gv�O�l
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and Ma�ch 2 of tne year the deduction is to be effective.
See reverse side fo� additional instnictions and qualificalions. �l G��
GIBSON COUNTY pU01TOR
a
(owner or contract buyer - see
Tauing Distrid
♦ � / �
Assessed value of real property as of
March 1, current year
If no, what is his / her exad share of interest?
If name on record is
on
number / legal description � Record number
�%—�C� a�o�i��{�0�0 �—�Jc�bber /�./
Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or
March 1, wrrent year owneR ❑ Yes ❑ No
ihan that of applicant, indicate b=1ow:
If owned with someone other lhan spouse, indicate with whom.
�me of mortgagee or contrad seller n ,., ��
L 0./
Address of mortgagee or conVad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
of assignee (nurnbe�and sfreet, city, state, ZIP code)
Dces applicant own property in any olher If yes, what caunty? What Taxing Distrid?
county in Indiana?
Dra���er\'O.Q�.c'..,1.�.l..a �UDITOR
Deduction appro�ed
20 �
Signature
Card NO . .....................
County Auditor
zo
Is the property in question:
❑ Real Property ❑ Mobile Hane
Has this dedudion been requested on
property for current yeaR � Yes ❑ No
zo
Date
20
We certiy under the penalty of perjury that the above and foregoing infortnation is true and corred and thal the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
name)
�
or by IC 6-1.1-12-.07
executed Power of Attomey
resident address ot applicant Address of authorized person
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