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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR DEDUCTION FROM ASSESSED VALUATION
S J State Fortn 43709 (RS / 4-03)
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PresaiDed by Deparlmant of Local Gtivemment Finance
Coun Township Year
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INSTRUCTIONS: File Mark
To be filed in person or by mail with the CountyAuditor ol the county where the property is located. S E{' G
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Filing Dates: 1J Real Property: Dunng the 12 months belore May 11 o)the year the deduction is to be eAective.
2) Mobile Homes assessed under IC 6-7.1-7: Between January 15 and March 2 0( the year the deductan;is to be effective.
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See reverse side for additional instnicfions and quali�cafions. � h�.� ;�p�70R
GIBSON C�'-
Applicani (owne� or
Taxing Distrid
- see 2st�ctior� on,eye�e side)
Assessed value of real property as of
March 1, wrrent year
If no, what is his / her exaa share of interest?
Key number / legal description Q/I Record number �
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Mortgage / Cantract indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, current year owneR 0 Yes ❑ No
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If owned with someone other than spouse, indicate with whom.
If name on record is different lhan that of applicant, indicale below:
'me of mortgagee or contrad seller � n/
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Address ot mortgagee or contract seller (number and street, ty, state, ZIP
Name of assignee or
Address of
owner or_holder.oi.m�rtna�o __ _
(numt Drawer NO....°��.��......
Is the property in question:
❑ Real Property ❑ Mobile Harie (IC 61.1-�
Does applicant own propert Ca I"C� �rO. ... S 7.� .....
ing District? Has this deduction been requested on
county in Indiana?
., , n ��� � G�I �� � property for current year?� Yes❑ No
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Deduction approved in ihe amount of:
20 �
Signature
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COUNTY AUDITOR
20 20 20
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County Auditor
20
Date
20
certify under the penalty of peryury that the above and foregoing information is true and correct and lhat the applicants was / were
ient of Indiana and owner of the aforementioned property on March 1, 20
�owners /ull name)
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Person authorized by duly executed Power of
or by IC 6-1.1-12-.07
of authorized person