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i a � STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�•i�c FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
� ..�%'J State Fortn 43709 (R6 / 5-OG) . ' ' ..' . ' . . � . . . .
� Presaibetl by Depariment of Local Govemment Finance - �
INSTRUCTIONS: OCT 1 5��! a�`
To be fi/ed in pe�son or by mail w8h the County A'uditor ot the county where the propeRy is located.
Filing Dates: 1)`Real Property: Dunng the 12 months'before June Il o/the year the deduction is to be,�6ective. �/
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March�2 ot the ye�f�Ba{e�{a�is to be elfective.
See �everse side for additional instructions and qualifrcations. GIBSON COUNTY UDITOR
Applicant
side)
Key number / legal description
u
� a�-la-b�- 4ol-oc�. /7 PaOg�i�'nber C� 7�o^L
d0
Assessed value of real property as of Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March t, current year March curtent year , owneR ❑ Yes ❑ No
�����'
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 diiferent than
of moAgagee or contrad seller
Address of mortgagee or
Name of assignee or othe
Address of assignee
applicanl, indicate below:
seller (number and stieet, aty, state, ZIP
owner or holder of mortgage
street, city, state, ZlPcode)
Does applicant own property in any other If yes, what couniy7__
county in Indiana? __-- � J� r
����(./'' r J
Deduclion approved in the � � � � � �
20� 20 �
� .- i �
Signature
County Auditor
Taxing Distrid?
TO R
�
❑ Real Prop�ly ❑ Mobile Horrre (IC 61.1-�
propertyforcurtent
20
20
ies[ea on
Yes� No
We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
name)
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
�v��w+n Ir+aaress or aucnonzea person
4 � ss �,�.i�. zzv