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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNEec
FOR DEDUCTION FROM ASSESSED VALUATION
SfaIC Fotm 43709 (R4 / 16-01)
Preuribed by Department of Lorat Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor of the county whe2 the propeRy is locafqc�eY (� 7�003
Filing Dates: 1) Real PropeRy: During the 12 months beloie May 11 0/ the year the deduction is fo TiA eflec�
2) Mobile Homes assessed under IC 61.1-7: Between January 15 and March of the year th Ceduction is to 6e e/%ctive.
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See ieverse side tor additional instructions and qualifications.
GIBSON COUNTY AUDITOR
Applica owner or contract buyer- see restric io �s on reverse side)
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Taxing Distrid Key numb legal descript9i n Record number �� �
y Q/ C�1 _ O�/�L/ _�� Page number z
/ / � d �
Assessed value of real property as of Mortgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, wrrent year owneR ❑ Yes ❑ No
If no, what is his / her exad share of interesl? If owned with someone other than spouse, indicate with whom.
If name on record is different Ihan that of appticani, indicate below: Is the property in question:
❑ Real Properly ❑ Mobile Horrie QC 61.1-�
me of mortgagee or contrad seller •
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Address of mortgagee or contract seller (number and street, ' state, ZIP �
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing District? Has this deduction been requested on
county in Indiana? property for current yeaR� Yes❑ No
COUNTY AUDITOR
Deduction approved in the amouni of:
2o Q,� za � zo 0� zo o zo � zo � Zo 0 9
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Signature County Auditor Date
�/ We ceAify under the penalty of perjury that the above and foregoing infortnation is true and corred and lhat the applicants was / were
residenl of Indiana and owner of the aforementioned property on March 1, 20
Si ture ( s ful�me) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Fu resident address of ap lica Address of aulhorized person
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