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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
's � � State Form 43709 (RS / 4-03)
w.
� Prestnbed by Depanment of Local Govemment Finance
INSTRUCTIONS: p E ��ijt� f�Q4
To be filed in person or by mail with the County Auditor of the county where the propeRy is located.
Filing Dates: 1) Real Property: During the 12 months belore May 11 0/ the year the deduction is to //ectiv,e.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the 6e.d ive.
See reverse side Ior additional instn�ctions and qualifications. GIBSON COU TY .4UDITOR
Applicant (owner
Taxing
buyer-see
side)
Key number / legal
Record number
C►�- ���� �9a � �`� 09
Page number
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, current year ownefl ❑ Yes ❑ No
V �
If no, what is his / her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is different lhan ihat of applicant, indicate below:
of moAgagee or contracl seller
Address of mortgagee or contrad seller (number and street,
Name of assignee or other owner or holder of mortgage
assignee (num6erand street, city, state, ZIP code)
Does applicant own property in any olher I If yes, what county? I What Ta
county in Indiana?
20
approved in lhe amount of:
20
COUNTY AUDITOF
20 � 20 �L 20
� P
County Auditor
s the property in question:
❑ Real Properfy ❑ Mobile Home (IC G1.1-�
^ ted on
�� ❑No
D�� �
����
D�- �°Li7 —
20
Date
20
certify under the penalty of peryury that the above and foregoing information is true and corred and that the applicants was / were
ent of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-t.t-12-.07
address of applican✓ IAddress of authorized person