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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
' FOR OEDUCTION FROM ASSESSED VALUATION Coun 7ownship Year
�s J State Fom: 43709 (RS / 4-03J
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� Ptesaibed by Department of Local Govemment Finance � -"1 �
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INSTRUCTIONS: Fil� Mark
To be filed in person or 6y mail with the CountyAuditor of the county where the property is located. S E P S Z��b
Filing Dates: 1J Real Property: During the 12 months be%re May 11 of the year the deduction is to be eRective.
2) Mobile Homes assessed under lC 6-L 1-7: Between January 15 and March 2 0l the �ear the deduction is to be eNective.
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See reverse side for additional instructions and qualifications. Q �
GIBSON COUNTY AUDITOR
Applicant(ownerorco rac 6uyer-see
Taxing Distrid
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Assessed value of real property as of
March 1, wrrent year
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Key number / legal description Record number
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Mortgage / Contrad indebtedness unpaid as of Is lhe applicant the sole legal or equitable
March 1, wrrent year owne(? ❑ Yes ❑ No
If no, what is his / her exaa snare of interest? If owned with someone other than spouse, indicate wilh whom.
If name on record is diHerent than Ihat of appliwnt, indicate betow: Is the property in question:
❑ Real Property ❑ Mobile Home pC 61.1-�
�me of mortgagee or contracl seller /Q
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Address of mortgagee or contred seller (number and street, i state, ZIP
Name of assignee or other owner or holder of mortgage
Address of assignee (number and st�eet, city, state, ZIP code)
Does applicant own property in any
county in Indiana?
Deduction appro�-'' �
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SignaWr, C`��a
:r I If yes, what county? What Taxing District?
3 COUNTY AUDITOR
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County Auditor
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Has this deduction been requested on
property for current year? Q Yes ❑ No
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Date
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/ We certiry 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
name)
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Person authorized by duiy executed Power of Attomey
or by IC 6-1.1-12-.07
�ess oi appucam IAddress of authorized person
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