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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (RS / 4-03)
PrescnEed py DepartmeM of Lo�l Govemmeni Fina�e
Coun Township Year
wsrRUCnoNS: JUL 0 5F�ie Ma�
To 6e filed in person or by mail with the County Auditor ol the county where the property is located. Z��6
Filing Dates: 1J Real Property: Dunng the 12 months before May 11 of the year the deduction is to be eflecfive.
2) Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 oI the ye he deduction is to be eRective.
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See 2verse side (or additional instn�ctions and qualifrcations. Q Q'
GIBSON COUNTY AUDITOR
Tauing
or contract buyer - see r�trictions on reverse
c1 Key number / legal description
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number
number
Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curzenl year March 1, current year � owneR ❑ Yes ❑ No
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Ii �io, what is his / her exad share of interesl? If owned with someone other than spouse, indicate with whom.
If name on record is different than lhat of applicant, indicale below: Is the property in question:
of mortgagee or contrad seller
Address of mortgagee or contract selier (num7er and street, city,
Name of assignee or olher owner or holder of moAgage
Address of assignee (num6er and stieet, city, state, ZIP code)
Does applicant owo property in any other � It.•�_., what county?
county in Indiana? I
Deduction approved in the amount of:
20
Signature
❑ Real Property ❑ Mobile Hmie (IC 6-1.1-�
ZIP
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'ypp, � � �, >.sted on
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COUNTY AUDITOR
20 Q� 20 � 20 �
1 �
__ County Auditor
20
Date
20
We ce�tify under the penalty of perjury that the above and forepoina informaGOn is true and corred and thal lhe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
/owners f��u „amr.)
Person authnrized by duly executed Power of Attomey
or by IC 6-1J-12-.07
resident address of applicant - _ �Address of authonzed person