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STATEMENT OF MORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (RS / 403)
P'escnDetl Dy Department ol Lacal Gtivemment Finance
INSTRUCTIONS:
To be filed in person or by mail with fhe County Auditor of the county where the property is loca���. /�
Filing Dates: 1) Real Property: Dunng the 12 mon[As before May 11 of fhe year the deduction is to be�He�ctile.
2J Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the year the deduct��s to 6e e/(ective.
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GIBSpN Cp��TY AP
Applicant (ownerorconfract uyer- see restriction on verse side) ��'^
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Taxing Dislrid Key numb /1 gal description Record number ^�
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D/p ^ ��Oq � Pagenumber C���
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Ass ssed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, cunent year March 1, current year owne(? 0 Yes ❑ No
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Ii no, what is his / her exact share of interest? If owned with someone other fhan spouse, indicate with whom.
If name on record is diHerent than that of applicant, indicate below: Is the property in question:
❑ Real Property ❑ Mobile Hort�e pC 61.1-�
�me of mortgagee or contract seller
/ / .
Address of mortgagee or conl�aG seller number and st et, city, stat , ZIP
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Name of assignee or other owner or holder of mortgage
Address of assignee (numberand st2et, city, state, ZIP code) __
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Dces applicant own property in any other If yes, what county? T � �'�.. s, 3,4 .� een requested on
counryinlndiana? Dra��'eC��•' ��� � �ear?❑Yes❑No
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couNT Card N�• .............
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Deduction approved in the amount of: �
20 ��% 20 � 20 9� 20 20 20 20
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Signature County Auditor Date
We certify under the penalty of perjury lhal the above and foregoing infortnation is true and corred and thal lhe applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature wners full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
F II resident address of a i � Address of authorized person