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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Strte Fwm 43709 (RS / 4-03)
Presaibed by Departmeni af Local Govemment Finance
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INSTRUCTIONS: OCT 1 %F�J�rk
To be filed in person or by mail with ihe County Auditor of the county where the property is /ocafed. �
Filing Dates: 1) Real Property: During the 12 months before May 11 01 the year fhe deduction is o e elfective. �{ In�
2) Mo6i/e Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0( a�r�a�A�gduition;is t�be.eryective.
See reverse side for additional instructions and qualifications. •� GIBSON �OUN7Y AU01T0? �
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Assessed value of real property as of
March 1, currentyear
If no, what is his / her exact share of interest?
Key numo@r / legal tlescription I Record number ��
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O/9- O/ �O ��� Page number ��a �
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Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year � 5 D D O, owner? ❑ Yes ❑ No
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If owned with someone other than spouse, indicate wiih whom.
If name on record is different than that of applicant, indicate below: / Is the property i
❑.Rra� a^^-�
�me of mortgagee or contrad seller - -'—
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Address of mortgagee or contrad seller (number and street, city, �TaWeY
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant ovm property in any other If yes, what county?
county in Indiana?
Deduction approved in lhe amouni of:
20 Q�
Signature
2005
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Card N�• ...................
VJhat Taxing District?
COUNTY AUDITOR
20 �-� 20 I�J r� 20
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County Auditor
❑ Mobile Home (IC E1.1-7)
Has this deduction been requested on
property for current year? � Yes 0 No
20 �� I 20
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We certify under the penalty of perjury that the above and foregoing infortnation is true and correct and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
;ull resident address o�f applT/cant Address of authorized person
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