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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
•+ �w� ! State Form 43709 (RS / 4-03) . .
� PresaiDed �y Department of Local Gtivemment Finance
iNSraucr�oNS: FEB 0 1 I�(�l9^a`�`
To 6e filed in person or 6y mail with the County Auditor of the county where the property is located.
Filing Dates: 1J Real Property: During the 12 months 6efore May 11 of the year the deduction is to be flective.
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 of the y�� is to be effective.
See reverse side (or additional ins[ructions and qualifications. GIBSON COUNTY AUD�TOR
or contract buyer- see
Taxing Disfricl f'
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an revej�s� side)
Record
� . , . - Page
Q�_� '7!,'D9_��
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Assessed value of real property as of MoAgage / Contrad indebtedness unpaid as of Is the applican the sole legal or equitabie
March 1, curtent year March 1, current year owne(? �s ❑ No
33�5��3-6
If no, whal is his / her exact share of interest? If owned wifh someone other than spouse, indicate with whom.
If name on record is differenl than that of applicant, indicate below: I� the property in question:
of mortgagee or contrad seller
Address ot.mortgagee or contract selier (number and street, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and streef, ciry, state, ZIP code)
Does applicant own property in any
county in Indiana?
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Signature
�S 4oL� /y .
approved in fhe amount of:
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If yes, what county? I What Taxing Distrid?
7 COUNTY AUDITOR
20 � 20 20
�
County Auditor
❑ Mobile Home (IC 61.1-�
Has this deduclion been requested on
propeAy for current year?� YesO No
20
Date
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We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (owners full name) ^
Person authorized by duly executed Power
or by IC 6-1.1-12-.07
of authorized person