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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
" FOR DEDUCTION FROM ASSESSED VALUATION
+ N� / State Form 43709 (RS / 4-03) _ . .
� Prescnbed by Department of Local Govemment Finance
Coun Township Year
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor of the county where the property is located. MAY 1 6 20�6
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction is to be effective.
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0( the year the de uction s to 6e e(fective.
See reverse side for additional instructions and qualifications. 4�� ��"`�
GIBSON COUNTY Al:D�TOR
Applicant
see
side)
Key number / legal description � Record number
J V , / �% � �/ L�o
/ , / _ /� (y` � � p ( 1 "/ O/ Q _ O�� �Q Page number 3 � �
LU,CLT /L Li�- `!/
Assessed vatue of real property as of Mortgage / Contract indebledness unpaid as of Is lhe applicant the sole legal or equitable
March t, current year March 1, current ear owne(? ❑ Yes ❑ No
� �d
If no, what is his / her exact share of interest? Ii owned wifh someone other ihan spouse, indicate with whom.
If name on record is diHerent than lhat of applicant, indicate below: Is the property in question:
morigagee or contrad seller
Address of mortgagee or contract seller (numbe{/hd street, city, state, ZIP
V
Name of assignee or other owner or holder oi mortgage
Address of assignee (number and street, city, state, ZIP
Does applicant own property in any other If yes, what county?
county in Indiana?
Deduction approved in the amount of:
20
Signature
❑ Real Properly ❑ Mobile Home QC 6-1.1-�
3
:
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Sv�A�� � n�G�%Q� 'n requested on
� yy �� ar?�]Yes�No
: y 3 �s �G -3s9�
COUNTY .._,.� , „n
20 _Q$_ 20 �� 20 20 20
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Couniy Auditor Dat
20
We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
�esident of Indiana and owner of the aforementioned propeRy on March 1, 20
address of
Person authorized by duly executed Power oi Attomey
or by IC 6-1.1-12-.07
o( authorized person