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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
Z _ FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R11/6-09)
Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the pmpe r to t
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought.
2)Mobile/Manufactured Homes not assessed as Real Property:Must file during the twelv 2) • �6 my Auditor
before March 31 of each year the deduction is sought 2 5 • County Recorder
See reverse side for additional instructions and qualifications. APR 2 5 'LU13
Appa ant weer or contract buyer-rictions
-(on reverse site)
1� ( J 13Page number
Ta Key mbar/legal desaiption
ii.t — a6//_/), -.t o3-00/, /S3 -o a18 GIBSON CO NTYAUDITO a l4Co
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortg e/Contras ebtedness unpaid as of Is the appG nt the sole
March 1,current year March 1,cement year date of legal or equitable owner?
3aooD ❑ 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
❑Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortga4e or contract serer , yr _
Address of mortgagee or contract seller(number/r and street,city,state,and ZIP codede)
Name of assignee or other owner or holder of mortgage _
Address of assignee(number and street,city,state,and ZIP code)
Local,.
o L AyLE
Does applicant own property in any other If yes,what county? ited at property
county in Indiana? ❑ Yes
❑ No / 2 J - 1 t Y! Yes ❑ No
CO /^ � Ol
Deduction approved in the amount of: Coos
a 20 20 20 20 21) 20 20
Sg' n ot County AWitar County Date(month, year)
II I We certify r the peenaCallty of pequry tthat 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.
hSignature(owners MI name) Date(month,day.year)
'I :/.
kFull resident address�jpbont(numbe nd street,city,state,and ZIP code) +
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,Eby,year)
Address of authorized person (number and street,city,state,and ZIP code)