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`°rt�° STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
-° ° FOR DEDUCTION FROM ASSESSED VALUATION Count Township Year
y / Slate Fofm 43709 (R4 / 70.07 )
��� � Prescribetl by Depanment W Loral Govemment Finance
INSTRUCTIONS: ---��g�----��g g e
To be filed in person or by mail with the County Auditor of the county whe2 the prope�ty is loc�. N@ ��
Filing Dates: 1) Rea/ PropeRy: Dudng fhe 12 monfAs be(ore May 11 of the year the deduction �} ro b9� /f&cr�ve.
2) Mobile Homes assessed under IC 6-1.1-7: Behveen January 15 and March 3'�0/ fhe year the deduction is to be e/fective.
See reverse side far additional instrUCtions and quali�cations. MAY i � 20�2
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Appliwnt (ow or ract b er- s restrictions on erse side) �/
�� GIBSON COII��" �UDITOft
Taxing Distrid Key number / lega d uiption Record number D/
� bS-b �/a3 /-oa Page number C� p/ /
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Assessed valu f real prop as of Mortgage / Contracl indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, currenl year March 1, current year ownef? ❑ Yes ❑ No
� �-�
If no, what is his / her exact share of interest? f owned with someone other than spouse, indicate with whom.
If name on record is different than that of appticant, indicate below: Is the property in question:
� Real Property ❑ Mobile Home pC 61.1-�
�me of mortgagee or contract seller �
Address of mortgagee or contrad seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for current year? � Yes� No
COUNTY AUDITOR
Deduction approved in the amounl of:
Zo � �;.oti zo j� zo Q� Zo � zo 0� zo � zo Q�
5 tAao� PrAOo� � �
Sign ure ¢�j County Auditor Dale
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�� We certify under the penalty of perjury that the above and foregoing information is true and correcl and that ihe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
ignature (owners full name) Person authorized by duly executed Power of Attorney
� or by IC 6-1.1-12-.07
Full resident address of applica Address of authorized person
y� '� 1 i�1c 13