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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Townshi Year
�+ ! �State Fortn 43709 (R5/4-03) � .
�«•
� Pfesc(ibed by Departmem of Local Gtivemment Finance
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor o( the county whe2 the property is located. � p N 2'] 2��(
Filing Dates: 1) Real Property: During the 12 months be%re May 11 0/ the year the deduction is to be'LNective.
2J Mobile"Homes assessed under IC 6-1.1-7: Between January 15 and March 2 o(the year the de� t�is to 6e e(fective.
See reverse side for additional ins[ructions and quali�cations. �
GIBSON C�NTY AUDITO�
(owner or contr�ct buyer- see
Dislrid
Assessed value of real property as of
March 1, current year �
no, what is his / her exact share of
side)
�
Key number / legal description Record number ,,p� �
�� � g- oa3 �a � Page number V
Mortgage / Contract indebtedness unpaid as of Is the applica t th sole legal or equitable
March t, cu e year owneR ❑ Yes ❑ No
V� — .
If owned with someone other than spouse, indicale with whom.
If name on record is difterent than that of applicanf, indicate
'me of mortgagee or contract seller
. ���,`/ �
Address of mortgagee or contrad seller (number and st� ei,
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st2et, city, state, ZIP
Does applicant own propeRy in any other I If yes, what county?
county in Indiana?
Deduc[ion approved in the amount of:
20 20 � _ 20
e �
Signalure
ZIP
What Taxing District?
COUNTY AUDITOR
20
County Auditor
20
Is the pi
❑ Real
❑ Mobiie Home pC 61.1-�
m
Has this deduction been requested on
properly for current year? � Yes � No
20
20
We rtify under the penalty of perjury that the above and foregoing infortnation is true and corred and that the applicants was / were
�es�nt of Indiana and owner of the aforementioned property on March 1, 20
(ull
Person authorized by duly executed Power o( Attomey
or by IC 6-1.1-12-.07
authorized person