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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
State Fwm 43709 (RS / 4-03)
P25cnEeA Dy Departmeni of Loral Govemment Finance
INSTRUCTIONS: .
To 6e filed in person or by mail with the County Auditor of the county where the property is located. I �� 2��5
Filing Dates: 1). Real Property: During the 12 months before May 11 0! the year the deduction is to b�+�c
2) Mo6ile Homes assessed under IC 6-1.1-7: Between January 15 and March 2 0( the year [he deduction is fo be eflective.
See reverse side for additional instructions and qualifications. �� ,Q�
GIBSON COUNTY AUDITOR
Applicant (ownerorcontract buyer- see restrictions rever side)
Taxing Distrid Key ber / legal de c iption Record number � �r
� o� -oa���� �'
Page number � �
Assessed value of real property as of Mortgage / ContraG indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, current year March 1, current year owner? ❑ Yes � � No
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� If no; what is his �! her exact share of interest? If owned with someone other than spouse, indicate with whom.
If name on record is diHerent ihan that oi applicant, indicate below: Is the property in question:
� ❑ Real Property O Mobile Home QC 61.1-�
�me of mortgagee or contraU seller
Address of mortgagee or contract seller (number and sfreet, city, s e, ZIP
Name ot assignee or other owner or holder of mortgage �
Address of assignee (numberand street, city, state, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid? Has this deduction been requested on
counry in Indiana? property for wrrenl year?� Yes� No
COUNTY AUDITOR
Deduction approved in the amount of:
20 � �20 � 20 �� 20 20 20 20
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Signature County Auditor Date
��' certify under the penalty oi peryury that the above and toregoing information is true and correcl and that the applicants was / were
. a r sident of Indiana and owner of the aforementioned property on March 1, 20
' nature ners (ull name Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
Fu resident addr s of nt Address of authorized person
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