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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Stata Fam 43709 (R6/ 5-06) - � � ' '
Resvibed by Department of Lonl Govemment Finance
Coun Township Year
INSTRUCTlONS: File Mark
To be filed in person o� 6y mail with the County Auditor of the county where the p�operty is located. � 0 � T ] 1 2���
Filing Dates: 1J Real Property: Dunng the 12 months before June Il of the year the deduction is to 6e effective.
2) Mobile Homes assessed unde� IC 6-1.1-7: Between January 15 and March 2 o(the year the deA tion is o be efiective.
See reverse side !or additional instructions and qualifications. a(�/ r�Q�
GIBSO�OUNTy AuplTOii
Applicant
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cont%^ M ' .Q+ g�e �
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vatue ofreal property as of
March 1, aurent year
If no, what is his / her exad share of interest?
name on record is different ihan that of
of mortgagee or conVad seller
on reverse
Key number / legal description � Record number
� � �O �' �O• _ ^ ., � Page number
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MoRgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or
March 1, current year owne(? ' ❑ Yes � No
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below:
If owned wilh someone other than spouse, indicate with whom.
Address of rrortgagee or contract seller (number and street, city, state, ZIP
Name of asaipnee or other owner or holder c` --'-----
assignee (number and sheet, city
Does applicarM own property in any other If y
counry in Indianal
Deduction
20 O Q
/
Signature
the amounl of:
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Dra�i�er NO..�:%.'.7y�?a
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COUNTY AUDITOR
20 20 20
County Auditor
Is the properiy in question:
❑ Real Property ❑ Modle Horne QC 6�1.
Has this dedudion been requested on
property for curtent yeaR � Yes ❑ No
20
Date
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We certify under the penalty of perjury that the above and foregoing information is true and corred and that ihe applicants was / were
'esident of Indiana and owner of the aforementioned property on March 1, 20
lull name)
Person authorized by duly executed Power of Attomey
or by IC 6-1.7-12-.07
authorized person