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STATEMENT OF MORTGAGE OR CONTRACT IND TEDNESS
FOR DEDUCTION FROM ASSESSED VALUATIO Coun Township Yes
� �� ! State Fwm 43709 (RS / 4-03) /1 (
Prescri0ed bj Departmeni of Local Govemment Finance (� � l j\ �
�TRUCTIONS: ` � File Mar�k
oe filed in person or by mail with the County Auditor o7 the county where the is�ate � ����
Filing Dates: 1J Real Property: During fhe 12 months before May 11 of the year t ction is t�l/ective.
2) Mobile Homes assessed under IC 6-1.1-7: Between January arch 2 of the year�t�eVdeduatia���� be effective.
See reverse side lor additional instructions and qualifications. i ,.
� `����v�.�—('
Assessed value of real property as of
March 1, current year
If no, what is his / her exact share of interest?
m
GIBSON COUh�I t' tUDITOfl `
Key �ii nber / legal descriptio� Record nu r `Li�l'/9 �
I � -DD6g3 � Page number � �5�
Mortgage / ConVact indebtedness unpaid as of Is the applicant the sole tegal or equitable
March 1, curtent year owneR ❑ Yes ❑ No
�
If owned with someone other than spouse, indicate with whom.
If name on record is diHerent than that of applicant,
Name of mortgagee or contract seller
of mortgagee or contrect seller (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address o( assignee (num6er and street, ciry, state,
Does applicant own property in any
county in Indiana?
Deduction approved in the amount of:
20 20
_ �
Signature
I / We certify
aResident of
r If yes, what counry?
COUNTY
20 � 20 0 7
�
County Auditor
s the property in
❑ Real Property ❑ Mobile Home (IC 67.1-7)
� . �"D� � D �' ��5 9
�
98�-39 S � :
20 � 20 ��
Y /
Date
�
�
en requesied on
�ar? ❑ Yes ❑ No
�
the penalry of perjury that the above ai�d foregoing information is true and correct and that the applicants was / were
a and owner of the aforementioned property on March 1, 20
applicant
i
. �_
or by IC 6-1.1-12-.07
Address of authorized person