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iei °� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
°i'�' FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
�i+ State Form 43709 (R6 / 5-OG) ' . - ' . . .
�• Presaibed by Department of Local Gavemment Finance �
INSTRUCTIONS: Fiie Maric
To be tiled in person or by mail with the County Auditor o( the county where the property is located. rT �%l ZO� �
Filing.Dates: 7) Real Property: During the� 12 months 6e%ie ,lune 11 of the year the deducGon is to �2�c�J/ecbve.
2) Mobile Homes assessed unde� IC 6-1.1-7: Between January 15 and March 2 o/the year the de�ur,tion is to be effective.
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See reverse side for additional instnictions and qualifications. O'' �� ��
GIBSON COUNTY AUDITOR
Applicant
Dislrict
-see
Key number
.
_ I _
o� 6 -la-b7 -303 -oDy.3 a
Assessed value of real property as of Mortgage / Contrad i�
March 1,,wrrent year March 1, current year
�'Ssi
If no, what is his / her exact share of interest?
If name on record is different than ihat of applicant, indicate beiow:
' . ' �� _ . � .
mortgagee or
number
as of I Is the applicant the sole legal or
owneR ❑ Yes ❑ No
If owned with someone other than spouse, indicate with whom.
Address of mortgagee or conVad seller (number and street, ciry, state,
Name of assignee or otfier owner or holder oi mortgage
Address of assignee (num6er and street, city, sfate, ZIP code)
Does applicant own property in any other If yes, what county? What Taxing Distrid?
munty in Indiana?
_ COUNTY AUDITOR
Dedudion approved in the
20 V b
P
Signature _
Dra�rer Np,.c`�(�jrl
20 J .........
_ Card i\'O. .... �0�� /
_ � 55�....
20
s the property in question:
❑ Real Property ❑ Mobile Home QC 67.
Has this deduclion been requested on
property for curtent yearT � Yes ❑ No
20
Date
20
We certify under lhe penalty of perjury that the above and foregoing information is true and corred and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
full1 n'am`e)
W .
Person authorized by duly execuled Power of Attomey
or by IC 6-1.1-12-.07
swent aaaress ot{ a�pp�u�can Address of authorized person
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