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�ai "� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
�i�� FOR DEDUCTION FROM ASSESSED VALUATION Count Township Year
. / Stale Form 43709 (R6 / 5-06) � . ' . . . .
� M� Presaibed by Depanment of Local Govemment Finance - '"`i
INSTRUCTIONS: File Mark
To be filed in person or by mail with the County Auditor of the county where the propeRy is /ocated. N� � l 6 2���
Filing Dates: 1) Real Property: During the 12 months before June Il of fhe year the deduction is to be eflective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and Maroh 2 o(the yea�Yhe�leduc��o be elfective.
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See reverse side foradditional instructions and qualifications. _ GIBSON C UNTY AUDITOR
Applicant (owne�
iD .
Taxing Distrid
see restrict�ons on ieverse side)
number / legal descriplion U Record number
o�l.S-6� '
� Page number
-u- -aby-a c�gg
Assessed value oi real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant t e sole legal or equilable
March 1, currenf year March 1, current year � owneR � ❑ No
�8��a
16 no, what is his / her exact share of interest? If owned wilh someone otlier fhan spouse, indicate with whom.
If name on record is diHerent than that of applicant, indicate
mortgagee or contrad seller
Addrese af mor�qagee or conVaIX seller (number and street, city, state, ZIP
Name of assignee or other owner or holder oi mortgage
(number and st2et, city, state, ZIP code)
property in question:
❑ Modle Home QC 61.
Does appGpnt own property in any other If yes, what counry? W Dra�ti�er ��70,0.?- ��`� requested on
county in Indiana? "' ••�•. ? � Yes 0 No
Card 1\'O . ....... ...........
approved in the amount of:
20 ��
Signature
� /'
couNrY auo� � �R
20 20 20
County Audilor
20
Date
20
ceAify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
lent of Indiana and owner of the aforementioned property on March 1, 20
� (ow� ners rm� naqle�, c
�ti � ��
ent address of applipnl
Z.y �l �.-�-, � �s o �,
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person