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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNES�
FOR DEDUCTION FROM ASSESSED VALUATION
Siate Fwm 43709 (RS / 4-03)
PrescriDed Dy Departmeni of Loral Govemment Finance � �
INSTRUCTIONS:
To be filed in person or 6y mail with the County Auditor o) the county where the property is locatedn p
Filing Dates: 1) Real Property: During the 12 months be%re May 11 0/ the year the deduction is to'6�'Af/�ct�e2�06
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0( the year the deduction is to be effective.
See reverse side for additional instructions and quali�cations. �a� ,�d
G�BSON COUNTY q DITOR
Applicant (owneror
Taxing
Assessed value of real property as of
March t, currenl year .
If no, what is his / her exact
interest?
number / legal
Record
�/ 7.,� as a� --�T � Page numbi
V
Mortgage 1 Contracl indebtedness unpaid as of Is the a
March 1, current year owner?
9500 0
name on record is different than that of applicant, indicate below:
I the sole legal or equitable
❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
,me of mortgagee or contraIX seiler n ^�
.
�..� V
Address of mortgagee or contract selier (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
of assignee (number and streef, city, sfate, ZIP code)
Does applicani own property in any other 1( yes, what county? What Taxing Districl?
county in Indiana?
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Signature
COUNTY AUDITOR
approved in the amount of:
�zo_p�_ zo 09 zo zo
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County Auditar
Is the
❑ Real Property ❑ Mobile Hane pC 61.1-�
Has this deduction been requested on
propeAy for current yeaR � Yes � No
20
zo
certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March t, 20
Signature
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Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
authorized person