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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fartn 43709 (RS / 4-03)
PrescriDed by Department of Laral Govemment Finance
INSTRUCTIONS:
To be �led in person or by mail with the County Auditor of the county wAere the property is located. n C T 1� 2003
Filing Dates: 1) Real Property: During the 12 months befo2 May 11 of the year the deduction is to be eHectiv�.
2) Mobile Homes assessed undei IC 6-1.1-7: Between January 15 and March 2 of the year the deduction is tO be eN/eIctiv//e.��
See reverse side /or additional instructions and qualifications. /�Z� "" ��� ��
i GIBSON CQUIJTY AUDITOR
District
s�e mcnons on revers i<
/
Key number / legal
� �/9 i�
Assessed value of real property as of
March 1, cunent year
If no, what is his / her exact
name on
mortgagee or contract
of
number
a7o
Mortgage / Contract indebtedness unpaid as of Is the applicant the sole legal or
March 1, current year owner? ❑ Yes � No
Address ot mortgagee or contract seller (number and
of assignee or other owner or holder of mortgage
Address
street,
Does applicant ovm property in any
counry in indiana?
Deduction approved in the amount of:
20
Signature
20 () �
�
stale,
5 fo �"� �
If owned with someone other than spouse, indicate with whom.
city, state,
If yes, what counry? � What Taxing District?
COUNTY AUDITOR
20 �i � 20 Q� 20
Counry Auditor
❑ Real
�
❑ Mobile Home (IC E1.
Has this deduction been requesied on
property for current year? ❑ YesO No
20 � 20
�
Date
certiTy under the penalty of perjury that the above and foregoing infortnation is true and correct and that the applicants was I were
lent of Indiana and owner of the aforementioned property on March t, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
of authorized person