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//..,, o STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNE.,., County I Township Year
! � FOR DEDUCTION FROM ASSESSED VALUATION �{
State Form 43709(R11/6-09)- Gibson 'I-ia stad�T1 3
Prescribed by Department of Local Government Finance FjpIT
e
INSTRUCTIONS:
To be filed in person or by mail. Fred OS 2013
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. L
Must be filed with the County Auditor or County Recorder of the county where the property is located ❑ County Auditor
on or before January 5 of the immediately succeeding calendar year. • un earS@r
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the
county where the property is located during the twelve(12)months before March 31 of each year thGIBSON COUNTY AUDITOR
deduction is sought.
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
Derrick R.Coy and Kelli J.Coy
Taxing District Key number/legal C ta o5 94-0014 Record nu be Page number
Gibson 26-23-18-100-000L0U 0t4- ,QQ� I 17/70
Assessed value of real popery as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,anent year March 1,current year date of application legal or equitable owner?
26,300.00 0.00 232,667.00 GI Yes ❑ No
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 different than that of applicant,indicate below: Is the property in question:Annually Assessed
0 Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
First Security Bank
Address of mortgagee or contract seller(number end street.city,state.and ZIP code)
123 S.Green River Road, Evansville, IN 47715
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street.city,state.and ZIP code)
Does applicant own property in any other If yes,what county? What Taxing District? Has this deduction been requested on property
county in Indiana? for current year? ❑
❑ yes 12 No yes allo
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of County Auditor County Date(month,day,year)
1/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Signatur ' ors full na Date(month,day,year)
-/ ,, 3/19/2013
run resident address of applicant(numb fTjp{rr� =t,city,state,and ZIP code)
County Road 1200 South,H---. adt, IN 47639
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 I Date(month.day,year)
Address of authorized person (number and street,city.state.and ZIP code)