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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Slate FOrtn 43709 (R4/10-01)
Pfcwibe0 by DeDaNrent W Local Govemment Finance
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor o/ the county whe2 the prope�ty is located. APK �� 2��3
Filing Dates: 1) Real Property: During the 12 months beto�e May 11 0/ the year the deduction is to be e!/ecirv .
2) Mobile Homes assessed under IC 6-1.1J: Between January 15 and Maich 31 of the yea�deiiirction is to be eHective.
See reverse side (or addifional instnictions and qualifrcations.
GBSON COI:�'Ty q��p�rOR
Applicant (owner or contract 6uyer see sMctions on revers side) I_
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Taxin Distrid Key number egal description Record number �
�/QI D l�O 2/ _O� Page number �7„ _�
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Assessed value of real property as of MoAgage / Contred indebtedness unpaid as of Is the appliqnt the sole legal or equitable
March 1, curtent year March 1, curtent year owneR ❑ Yes ❑ No
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If no, what is his / her exad share of interesl? If owned with someone other lhan spouse, indicate with whom.
If name on record is difterent Ihan that of applicant, indicale below: Is the property in queslion:
❑ Real Properry ❑ Mobile Hmie QC 61.1-�
�me of mortgagee or conVad seller � �
Address of mortgagee or conVad seller (number and st et, city, state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (num6er and st2et, ciry, state, ZIP code)
Does applipnt own propeRy in any other If yes, what county? What Taxing Distrid? Has lhis dedudion been requested on
county in Indiana? property for curtent yeaf? � Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 �� 20 �_ 20 �� 20 �
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Signature County Audilor Date
I/ We certify under the penalty of perjury that the above and foregoing informalion is true and corred and that the applicants was / were
resident of Indiana and owner of the aforementioned property on March 1, 20
$�g{�ature (owners (ull name) Person authorized by duly executed Power of Attomey
�� or by IC 6-1.1-12-.07
Full resi ' faddre ot appliqnt Address of authorized person
�N a . (�
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