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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
SUte Fwm 43709 (R4 / 16-01)
PrescriOeG by Depa'tment of Loral Govemment Finance
INSTRUCTIONS:
To 6e filed in person or by mail with the County Audifor o/ the county whe2 the property is located. I � N 1 Q Z��3
Filing Dates: 1) Real PropeRy: During the 12 months belo�e May 11 of the year the deduction is to be e��ect�ve.
2) Mobile Homes assessed under IC 61.1-7: Behveen January 15 and Ma�ch 31 oI e year the deduyctlon is to be ecfive.
See reverse side for additional instructions and quali�catlons. /���yJ �`�,���
GIBSON COUNi�" .4UDITOR
Applicant
- see nestnaions on
Assessed value of real property as of
March 1, current year
If no, what is his / her exact share of interesi?
Key number / legal description
number
n vv v
n/ ry /�/�O/ S'— �� Page number / n
6! CJ 6<�J d 7'
Mortgage / ConVact indebtedness unpaid as of Is the applicant the sole legal or e
March 1, current y r owne(? ❑ Yes ❑ No
�U�d .ad
If owned with someone other than spouse, indicate with whom.
If name on record is different than ihat of applicant,
of mortgagee or contract seller
Address of mortgagee or contrad selier (number and st2et,
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP code)
Does applicant own property in any other I If yes, what county?
county in Indiana?
Deduction approved in the amounl of:
20 �_ 20
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Signature
❑ Real
ZIP
❑ Mobile Home (IC 61.
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DrawerNO........1..........
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Card NO.�,,,,,,,_„
What Taxi ; /� „�_ �ted on
����� :s ❑ No
COUNTY AUDITOR
20 20 20
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County Auditor
20 _�'j_ 20
P
Date
We certify under the penalty of perjury that the above and foregoing infortnalion is true and corred and ihat the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person