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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
SUIe Fortn 43709 (R4 / 10-01)
PteSCribe.W by DeOartment of Locai Govemmeni Finanre
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county where the property is located. av ,� 7 2�03
Filing Dates: 1) Real Property: Dunng the 12 months belore May 11 0l the year the deduction is to be�Frecfive.
2) Mobile Homes assessed under IC 6-1.1-7: Befween January 15 and March 31 0/ the year the deduction is to b�'e(/ective.
See reverse side loradditional instiucBons and qualifications. /�� ������
/ ' GIBSON COUNZ V' %U�ITOft
Applicant
see �estncUOns on
Key number / legal description � Record number
� � /�1 /Q_OO�pI� Pagenumber (�3�C,
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Assessed value of real property as of MoRgage / Contract indebtedness unpaid as of Is the applipnt the sole legal or equitable
March t, wrrent year Mar�rrenl year owner? ❑ Yes ❑ No
CQ��
If no, what is his / her exacl
If owned with someone other than spouse, indicate with whom.
If name on record is different than ihat of applicant, indicate below:
�me of moAgagee or contract seller � n
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Address of mortgagee or contred seller (number a street, city, state, ZIP
assignee or other owner or holder of mortgage
Address of assignee (num6er and street, city, state, ZIP code)
Does applicant own property in any other If yes, what counry? What Tauing Distrid?
counry in Indiana?
COUNTY AUDITOR
Deduction approved in fhe amount of:
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Signature
20
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County Auditor
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Is the property in quesGon:
❑ Real Property ❑ Mobile Home pC &1.1
Has this dedudion been requested on
property for curtent yea(? � Yes ❑ No
20� 20
P
Date
certity under the penalty of peryury that the above and toregoing infortnation is true and corred and ihat the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
Person aulhorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Full re �ent addres"s o�nf applicant n Address of authorized person
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