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/� � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
t\s,'�� FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
\�, w� .!I= State Fwm 43709 (R6 / 5-06)
� Presoibed by Oepariment of Loral Govemment Finarice
INSTRUCTIONS: � g � ��
To be tiled in person or by mail with the CountyAuditor of the county where the property is locat A
Filing Dates: 1) Real P�operty: Dunng the 12 months 6e(ore ,lune 17 of the year lhe deduc6on i be �e
2) Mobile Homes assessed unde� IC 6-1.1-7: Between January 15 and March 2 of the yea� the deduction is to be efiective.
See reverse side for additional instructions and qual�cations. N � � 1 3 2��6
Appticant (ownerorconfract y r- e tndio n v e sid d d'
GIBSON COUNTY AUDITOR
Taxing Distrid Key numbei / legal des ' on _ Record number
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6� � —� � 7 � �(� Page number �
Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applipnt the sole legal or equitable
March 1, current year March 1, wrrent year owneR ❑ Yes ❑ No
�IDDC'�
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, indicate below: Is lhe property in question:
❑ Real Property ❑ Mobile Home pC Cr1.1-�
me of mortgagee or conVad seiler
Address of mortgagee or wntrad seller (number and stieet, city, st e, ZIP � j� (�
o � V�TSS�S
Name of assignee or other owner or halder of mortgage
Address of assignee (number and st2et, city, state, ZIP code)
Does applicant own properfy in any other If yes, what couniy? What Taxing District? Has lhis dedudion been requested on
county in Indiana? property for current year? � Yes� No
COUNTY AUDITOR
Deducfion approved in the amount of:
zo za ('� 20 0 zo 2o zo zo
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Signature County Aud'Aor Date
' We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
residAnt of Indiana and owner of the aforemenlioned property on March 7, 20
ignature (owners /ull name) Person authorized by duly executed Power oi Attomey
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Full resident address of applicant u��-�p Address of authorized person
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