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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Stata Form 43709 (RS / 4-03) �
Prescribe0 Dy Depanment of Local Govemment Finance
Coun Township Year
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iNSrRUCnoNS: DEC 1 9 �I�"a"`
To 6e filed in person or by mail with the County Auditor ol the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months 6e(ore May 11 0/ tbe year the deduction is to be_effective.
2) Mobile Homes assessed under IC 6-1.1J: Between January 15 and March 2 o/the yea�t3e.de�t�"an is to be effective.
See reverse side for additional instrtrctions and qualificafions. GIBSON CO NU 7Y q 01 0�
Applicant
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Assessed value ofreal
March t, current year
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UKey number / legal description Record number Q J
� / x � � /Yy� �� _ �� Page number / /� �
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rty as of MoAgage / ContreU indebtedness unpaid as of Is the appliwni the sole legal or
March 1, wrrent year owneR ❑ Yes ❑ No
If ,io, whal is his / her exad share of
name on
than that of applicant, indicate
of mortgagee or contract seiler
Address of mortgagee or coNrad seller (numb`er and
Name of assignee or other owner or holder of mortgage
Address uf assig�
Does a
counry
Deduc
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Signa�ure
andst2�t, r.ity, state. ZlPcode)
- - � �•...� - .�•hat cv_uny?
Dra�vcr i\'p,0, f.. ��
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state, ZIP
with someone other than spouse, indicate with whom.
bVhat Taxing Distrid?
Card Np, , couNTV nuoiroR
I 2n Q� i 26 __�_�_ 20 i
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_ .__._ __ f,ounty Auditor
Is the property in que.
❑ R�i P�ouerni ❑
Home QC 61.1
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Has this dedudion been requested on
property for wrrent yeaf?� Yes❑ No
zo
Date
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1h�e ce�iihj unAer 1hc ;.�nalty of per;ur� �F,�i Ihe above and fomaoina information is hue and corred and Ihat the applicanis was / were
�esident of Indiana and owner of tha aforementioned property on March 1. 20 __
Person a��thorizerl by duly exewled Power of Nttomey
or by IG 6-1.1-12-.07
���/� l Address of authorized person
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