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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
S J Stata Fortn 43709 (RS / 4-03) ,�
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� Prescri�ed by Department o( Lacal Govemment Finance "r.�
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INSTRUCTIONS: S�� 2 [6 ��lark
To be filed in person or by mail wrth the County Auditor of the county where the property is located.
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year the deduction i to 6e effecfiye.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 the yea de J t'o '�eflective.
See Bverse side �or addifional instNCtions and quali�cations. GIBSO� COU`!TY �I�DITOR
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Taxing Dislri� '
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Assessed value of real property as of
March 1, wrrent year
If no, whal is his / her exact share of interest?
If name on record is different than ihat
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Address � � ��
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Does applic, �� � T
wunty in Indi.
Deduction approve
20
Signature
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Key number / legal
Record number /� 2
C/J
O/Q /� ?�/�%�� Page number 2 7
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Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrrent year ownef? ❑ Yes ❑ No
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If owned with someone other lhan spouse, indicate with whom.
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..�NTY AUDITOR
20 20 _� 20 �
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County Auditor
❑ Real
question:
❑ Mobile Home pC Fr1.1-�
Has this dedudion been requested on
propeAy for current yeaR 0 Yes ❑ No
20 �1 _ 20
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Date
/ We certify under the penalty of perjury lhat the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the atorementioned property on March 1, 20
Signature (owners full
Fuli resident address of
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Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
Address of authorized person