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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED.VALUATION
Slate Form 43709 (R6 / 5-06)
PresaibeC by Deparimer.t of Lonl Gwemment Finance
OCT�3 1 2007
INSTRUCTIONS: GIBSON COI�t�'P1'"kF�bITOR
To be frled in person o� by mail with the County Auditor of the county where the property is located.
Filing Dates: 1) Real P�operty: DuAng the 12 months 6e%re June I t of the year the deduction is to be effective.
2J Mobile Homes assessed under IC 6-1.7-7: Between January 15 and March 2 o(the year the deduction is to be el%ctive.
See reverse side for additional instructions and qualifications.
Ap licant (owner or contract buyer - see resfrictions on' nreverse side)
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T xing District y number / legal description Record number �v � 7
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Assessed vatue of real property as of MoRgage / Conlrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, wrrent year owne(? ❑ Yes ❑ No
39 �s-��. � , ..
If no, what is his / her exact share of interest? if owned with someone other than spouse, indicate wilh whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
0 Real PropeAy ❑ Moble Home QC 61.1-�
�me of mortgagee or contrad seller �
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Address of mortgagee or contrad seller (number and street, city, `state, ZIP
Name of assignee or olher owner or holder of mortgage ---- --_
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Address of assignee (num6erand street, city, state, ZlP code) Dra�ver ND,p�Q �% —��'J�
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Does applicant own property in any other If yes, what county? What Taxinc Ca �rd 1VQ, ��
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county in Indiana? . ,,�(�. (j_, /J
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COUNTY AUDITOR � '� 'r�D • � d
Deduction approved in fhe amount of:
20 ("l� 20 � q 20 20 20 20 20
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Signature County Auditor Dale
We certify under the penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
Signature (ow ers full nam /� • Person authorized by duly executed Power of Attomey
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F II resident ad r of applicant Address of authorized person
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