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STATEMENT OFMORTGAGE OR CONTRACTINDEBTEDNESS
FOR DEDUCTION FROM ASSESSED VALUATION
Slate Fortn 43709 (R4 / 1P-01)
Prescribe0 by Department ol Local Govemment Finance
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INSTRUCTIONS: �,.�AY ,� F�ep�J�
To 6e filed in person or 6y mail with the County Auditor o! the county whe�e the property is located. LUUL
Filing Dates: 1) Real Property: During the 12 months before May 11 of the year fhe deduction is to e effective. �
2) Mo6ile Homes assessed under IC 6-1.7-7: Aehveen January 15 and March 31 of t� year t d�'d�1crfan is to e e ctive.
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See reverse side for additional instructions and qualifications. GiBSON COUtJT'r' AUDITOR
Applicant (owner or contract b er - see resMctions on rever ide) ,
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Taxing Distri _ Key number / al description Record number
_ � I Page number 3
Assessed value of real property as of MoRgage / Contrad indebtedness unpaid as of Is the applicant the sole legal or equitable
March 1, curtent year March 1, current year owneR ❑ Yes ❑ No
If no, what is his / her exact share of interesl? If owned with someone other than spouse, indicate with whom.
If name on record is different than that of applicant, indicate below: Is the property in question:
� Real PropeAy ❑ Mobile Horne QC 6-1.1-�
�e of mortgagee or contrad seller ,
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Address ot mortgagee or contrad seller (number and street, city, state, ZIP
Name of 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 counry? What Taxing District? Has this dedudion been requested on
county in Indiana? property for current yea(? � Yes� No
COUNTY AUDITOR
Deduction approved in the amounf of:
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2o D zo �g_ 20 �l� zo �,� zo U zo n 7 zo �_
s, �' � P '�
Sig ature O 9 County Audilor Date
�Ne certify under the penalry of perjury lhat the above and foregoing informalion is true and corred and that the applicants was / were
esident of Indiana and owner of the aforementioned property on March 1, 20
Si ature (owners full name) Person authorized by duly executed Power of Attorney
or by IC 6-1.1-12-.07
ull ident address of applicant Address of authorized person