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^'� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
„_ _� FOR DEDUCTION FROM ASSESSED VALUATION
. . .� Stata Fwm 43709 (R71 / 6-09) � �
� Presaibed M DePartmeM o( Lttal GovemmeM Firence
� File Mark
INS7RUCTIONS:
To be filed in p? j���(�Q 1 F� �� ��
person w by mail wiN the CounryAuditw or Counry Recorder o1 Ne counry where the pro rty �
Filirg Dates: 1) Real Property Must file dunng the year for which the deducfion is soughL J� � � �'j [�J � 1 � Cpunty Auditor
2) Mo6ile / Manufectuied Homes rrot asseued as Real Property: Must h7e dunng the twe7ve (7�2) months
6e(o�e March 31 a( each year the deduction is sotghG ❑ County Recorder
C.'�.�
See reverse side for add�Onal instnrctions arrd qualifications. �
npp6rant(owrieror �er-seeresnrtion�m� vqse`ee) �- GIBSONCOUNTYAUDITOR
,.c
Y mal pfoperly as
�
If name m �emtl is dMe�t than ihaf ol appticant'oM'vate hebw
Name W mortga9ee a mntrxl seDer
Add2ss of mMga9ee w mntrad
se0er (number and sfreet,
w tqlder N mortgz
AdCress of asvgnee (number arM street a+y. slate.:
DoeS appliCan[ wm poperty in any oNer
munry in Ind'ena? ❑ Yes
❑ No
Deduction approved in Ihe amouni of:
20 20
:iO�fl
rtgage / Conbafl'vdebtedness unpaid as of Is Me app�xant Ne sde
e��07Ri � ❑ Y� 0
tt awneE �viM 5omeo�
tt�an spouse. iMirate wiih whom
Dra���er NO... �� �:�.......
Card NO. ....°.?3a�.....
� 55, o��. �
20 � 20_
Caunry
E(i�]
Is C�e property in 7uestim: MnuaM Assessetl
I] Real Pfoperly Q MnuallyAssessed
as ma aeaWim oee� ,eq�estea «� a�a�'m
vcurtervYraR ❑ Yes ❑ �
20 � 20
I/ We certify urder the penalry of perjury Mat e above and faegning intom�ation is W e and cortect antl that Ne aDW���t is a resideM of Intliana aM
ovmer I con buyer of the aForemen " roperty on date applicatlon is filed.
re(owne nartre) Data (rtmtli, daY. Yaa�
' ent dresso pplicant(n m rerM dty,sfefe, IPaotle)
xson aulMfrzetl by dWy esecuteE Po.er UAttvriey rn b/ IC 6.t-12O.7 ' _ Date (monM, Ea}; ysa�
IAress of authassEd per:un (numberarM sbeet cky, sfafe, aM ZIP mde) .