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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' ' FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
+ �_� ! State Fwm 43709 (R5/ 4-03)
� Presaibed by Department ol Local Gov¢mmem Pinance
�
wsrRUCnoNS: AUG 3 1 2�5^^a�`
To be /iled in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: Dunng the 12 months be%re May 11 0/ the year the deduction is to be efiective.
2J Mobile Homes assessed under IC 6-1.1J: Between January 15 and March 2 0/ the�'r � d�dLcjj,on is to be effective.
See reverse side for additional instructions and qualifications. ��
GIBSON COUNTY AUDITOR
Applicant (owner or contract
Taxing
W �
Assessed value of real property as of
March 1, current year
If no, v+hat is his / her exact share of interest?
on
Key number / legal description
D O I
Record number
number
Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legzl �
March 1, current year owner? ❑ Yes ❑ No
If name on record is differen[ lhan that of applicant, indicate below:
of mortgagee or contraU seller
If owned with someone other ihan spouse; indicate with whom.
Address of mortgagee or contred selier (number and street, city, state,
Mame of assignee or other owner or holder of mortgage
Address of assignee (number and st�eet, city, state, ZIP code)
Does applipnt own property in any other If yes, what county?
counry in Indiana?
Deduction approved
20
Signature
What Taxing District?
COUNTY AUDITOR
in the amouM of:
20 20 � 20 20
� P
County Auditor
❑ Real
❑ Mobile Home pC 61.
Has this deduclion been requested on
property for current yean � Yes ❑ No
20
Date
20
We certify under the penalty of perjury that the above and foregoing information is true and corred and thal lhe applicants was / were
'�es}dent of Indiana and owner of the aforementioned property on March 1, 20
full name)
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Fuil resTdent address of applicant ^ � _ �P�dress of authorized person