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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
. w� J Stale FOrm 43709 (RS / 4-03) . � ��
� PrescriDetl �y Departmeni of local Gdvemment Finance
INSTRUCTIONS: FEB IFi� ��)
To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real PropeRy: During the 12 months be%2 May 11 0/ the year the deduction is to 6e eff y
2J Mobile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0/ the year tM E�i�ct� U be effective.
See 2verse side for additional instructions and quali(cations. GIBSON COUNTY AUDITOR
Applicant (ownerorcontracf buyer- see resfnctions on reverse side)
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Taxing Disirict Key number / legal description Record number
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' Page number
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Assessed value of real property as of Mortgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, wrrent year March 1, current year ownef? �Yes ❑ No
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If no, what is his / her exact share of interest? Ii owned with someone other than spouse, indicate with whom.
If name on record is different lhan that of appliwnt, indicate below: is,thne property in question:
L�Real Property ❑ Mobile Hmie QC 61.1-�
�me of mortgagee or contrad seller
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Addr s of mortgagee or contrad seller (number and sf�eet, city, state, ZIP �4
Name of assignee or other owner or holder`of mortgage '
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Address of assignee (numberand street, city, state, ZIP code) Drawer NO ...................
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Does applicant own property in any other If yes, what counry? What Taxing C Card NO . ..................... i
county in Indiana? �UV C� _� 22 Z o
COUNTY AUDITOR
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Deduction approved in fhe amount of:
20 i 20�� 20�_ 20 20 20 20
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Signa ure County Auditor Date
� We certify under the penalty of peryury that the above and foregoing information is true and correct and lhat the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
Sig ture (owners full name Person authorized by duty executed Power of Attomey
,�' 4, _ �� J or by IC 6-1.1-12-.07
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resident address of applicant Address of authorized person
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