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�ei 4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
s' � FOR DEDUCTION FROM ASSESSED VALUATION
� State Fwm 43709 (R6 / 5-06)
��� Presvibed by Department of Loral Gwemmen� Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Audito� of the county whe�e the property is locafed. AR 1 8 2��$
Filing Dates: 7) Real Property: During fhe 12 months befoie June I1 ot the year the deductron is to be elfectiv�
2) Mo6ile Homes assessed unde� IC 6-1.1-7: Behveen January 15 and March 2 o/the year the ded�bn is� bg el(ective.
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See reverse side for additional instiuctions and qualifications.
/1 • GIBSON COUNTN AUDITOR
Applicant
Disirid
reverse
Key number / legal desuiption
c�la /a-07�C�1-c�a. ��s �
Assessed value of real properry as of MoRgage / Contract indebtedness unpaid as o�
March 1, wrrent year March 1, current year s� ?s6 /
���CJ �
I( no, what is his / her exact share of interest?
i � � �
number � S 3 (o
Is the applicant the sole legal or
owneR ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
If name on record is diiferent than that of applicant, indicate below:
�e of moAgagee or contred seiler
Address of mortgagee or contract seller (nu r and stieet, city, sfate, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and street, city, state, ZIP code)
Dces applicant own property in any other If yes, what county?
county in Indiana?
Deduction approved in the amount of:
20
Signature
20
What
COUNTY AUDITOR
20 20 20
County Auditor
Is the property in question:
D Rea1
� �P
erty ❑ Mobile Home QC G1.
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D►•a�vei• NO�QI� .. ���G
� ted on
��Yv �'�. ' � � s�No
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��y� ���� 3sa.00 �
20
Date
20
under the penalty of perjury that the above and foregoing information is true and correct and thal ihe applicants was / were
Indiana and owner of the aforementioned property on March 1, 20
Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
Address of authorized person