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•aSTATEMENT OF MORTGAGE OR CON I T ) County Township Year
FOR DEDUCTION FROM ASSESSED VAL II N
i. State Form 43709(911/6-09)
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Prescribed by Department al Local Government Finance
INSTRUCTIONS: MAY 2 2013 File Mark
To be filed in person or by mall with the County Auditor or County Recorder of the co ty where the • located. Form feed with:
Filing Dates: 1) Real Property Must file during the year for which the deduction is .. f _kart
2) Mobile/Manufactured Homes not assessed as Real Property:M ..1 •• *I �f.-bra1}21.months County Auditor
before March 31 of each year the deduction is sought GIBSON COU Y • `1.71 I1JK County Recorder
See reverse side for additional in ctions and qualifications.
Applicant(awrmsor contract b - r. . verse site)
i t
T 1 ct �� f ad t ^' v0—wI-3V'r -I Record numper3 Page number
L3 C6
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract Indebtedness unpaid as of I Is the applicant the sole
Mardi 1,one year =tool
arrteM / date of eDP6�oon legal ar equitable ovrtrer?
�0� ❑ 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 ❑Atttuall Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract sager C C ' /
Address of mortgagee or contract seBer(number and sheet,city,state,and ZIP code)
Name of assignee or other owes or holder of mortgage
Address of assignee(number and street,sty,state,and ZIP code)
/` ^ I.Ifyes, county? What Taxing District? Has this deduction been requested on property
( /1�1 Y �J T��^ ^� s
for current year? ❑ yes ❑ No
�/ 1 ` Oo_ 1'L�'– COUNTY AUDITOR
i Lam/–IN
i3 – /(09 20 20 20 20
County ..- Date(month,day,year)
-
I I 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.
Sig c\(o -/s rNl name) Date(month,day,year)
ti Ay f�l . •
Iull resid1 Ef. 'ress.1j'pppfcant(number a 4cry,stale,and ZIP code) I� I\�� a /�`�
)O x333` {E. X 1141--- 4.. . `f, X411 r SI N- ! 7`. ` o
Person authorized by duty executed of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,city,state,and ZIP code) .