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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Stale Fortn 43709 (R4 / 1 P47 j
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Coun Township Year
Prewibe0 by Department ol Local Govemment Finance
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wsrRUCnoNS: APR 2 2 ���,a�
To be filed in person or by mail with the County Audifor of the county whe2 the propeiiy is located.
Filing Dafes: 1) Real PropeRy: During the 12 months be%�e May 11 0/ the year the deduction i to be eHective. /�
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 31 the ye r th de�d6ction � o eHective.
See reverse side foradditional insf�uctions and qualifications. GIBSON COUNT'i AU�
p t(ownt or contract buye - see rictions on reverse side)
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ing Di trict _ Key number / legal description Record number , O ,
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Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owner? ❑ Yes ❑ No
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If no, what is his / her exad share of inlerest? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Home (IC 61.1-�
N�ame of morigagee or contract seller r
Address of moAgagee or contract seller (number and street, city, ate, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applipnt own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
county in Indiana? property for wrtent year? 0 Yes � No
COUNTY AUDITOR
Deduction approved in the amount of:
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Sign ure n9 CountyAudilor Date
I/ We certify under the penalry of peryury that the above and foregoing information is lrue and corred and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20 .
ature ers 1 na e) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
F II re ' ent address of appli t Address of authonzed person
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