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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION Coun Township Year
State Form 43709 (R5/ a-03)
Presaibed Dy Department ot Local Govemment Finance
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INSTRUCTIONS: � File Mark
To be filed in person or by.mail with the County Auditor of the county where the property is loc�t 3 0 20�5
Filing Dates: 1) Real Property: During the 12 months belo2 May 1] o( the year the deduction is to 6e eflective.
' 2) Mo6ile Homes assessed unde� IC 6-1.1-7: Between January 15 and March 2 p—f,��h//e year th�duction is to be eRective.
See reverse side tor additional instructions and qualifications. v' 6Q �
. - GBSON COUNiY AUDITOR
Appiicant (owne� or contract buyer - see r strictio n reverse si e)
Ta�cing Distn Key number / legal description Record number ,p�5�'
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Assessed value of real property as of Mortgage / Contract 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 inieresi? � If owned with someone other than spouse, indicate with whom.
If name on record is different lhan that of applicant, indicate below: Is the property in question:
� � � � � ❑ Real Property ❑ Mobile Home (IC 61.1-�
�me of moAgagee or contract seller
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Address of mortgagee or contrad seller (number and street, city, stafe, ZIP
Name of assignee or other owner or holder of mortgage
hddress of assignee (num6er and st2et, city, state, ZIP code)
Does applicant own propeRy in any olhei If yes, what county? What Taxing Disirict? Has this deduction been requested on
county in Indiana? . propeAy for wrrent year?(] Yes❑ No
COUNTY AUDITOR
Deduction approved in the amount of:
20 � 20 �_ 20 20 20 20 20
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Signature Counry Auditor Date
� We certiy under the penalry of peryury that the above and foregoing information is true and corred and that the applicants was / were
�a resident o( Indiana and owner of the aforementioned property on March 1. 20
ignature (owners full name) Person authorized by duly executed Power of Attomey
or by IC 6-1.1-12-.07
II r dent addre s of appli t Address of authorizzd person
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