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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
++ / State Fortn 43709 (RS / 4-03)
� PiesfnDed Dy Depanment of laal Govemmeni Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where fhe property is located. � � T 1 7 2003
Filing Dates: 1) Real Property: During the 12 months before May 11 0/ the year fhe deduction is to be e!/ective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 ollhe year the ed�Hon is to be ective.
See reverse side for additional instructions and qualifications. .v
GIBSON COUt�TI' AUDITOR
or contra uyer - see stnctlons on
� � ���v n, d
District
Assessed value of real
March 1, current year
If no, what is his / her exact
` I Key �iJmber / legal`description
lJ
�0. G� �% ��"�-�JZ�
as of Mortgage / Contract indebtedness unpaid as
March 1, current ye
�����
e of interest? If owned with some�
If name on record is diHerent than that of applicant, indicate below:
,re of mortgagee or contrad seller /
l�
Address of mortgagee or wntrect selier (number and street, city, s,
Name of assignee or other owner or
and street,
Does applicant own property in any
counry in Indiana?
Deduc6on approved in lhe amount of:
20
Signature
20
r of mortgage
;iry, state, ZIP code)
If yes, what county?
What Taxi
COUNTY AUDITOR
20 20 b 7 20
� �
Counry Auditor
Record number
Paqe number
owner?
n�
��
t the sole legal or equitable
❑ Yes ❑ No
�'i�i
i
� �5�,�a��'
�
�
whom.
�ome (IC 6-1.1-7)
J ' /1 S �v ested on
� 3r � Yes❑ No
Drawer N ... ..
Card N� . ........... .......
_ 20 �_ 20
/
Date
We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was I were
esident of Indiana and owner of the aforementioned property on March 1, 20
nature (owners full name) Person aulhorized by duly executed Power of Attomey
/ %A/ (�n�/ . or by IC 6-1.7-12-.07
//// /.Y A1 �_ivvt . ����L�r� •
esident address of applicant Address of authorized person
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