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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
• .r, ; FOR DEDUCTION FROM ASSESSED VALUATION
I.j Preto Form d 43709 Department rtm/6-09) FILED
-+:•�- Presmbed by Department of Local Go+amcM Finance
INSTRUCTIONS:
filed with:
To be Med in person or by mad with the County Auditor or County Recorder of the county where the
property is keen s Form
Filing Dates: 1) Real Property Must Me during the year for which the deduction is sought. J U County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property Must Me during the twelve(12)months
before March 31 of each year the deduction is sought - ry Recorder
•
See reverse side for additional instructions and qualifications.
Appfimnl(owner or buyer-see resu ions on reverse side) GIBSON COUNTY AUDITOR
Taxer iefict tuber 13_ Pte_ /DI— n D 0. 016 / OO 4 Record 7u 0 Page� / K
Assessed value of coal property as of Fry Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid alas/d Is the applicant the sole
Math 1,cure&year March 1.current year date of appacati2n legal or equitable owner/
I ^t al 000
❑ Yes ❑ No
If no,what is his I 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. _ I Is the property in question:Annuaty Assessed
— r.1.,_et o.,,,„rt„ n Annually gesetmed
h
Name of mortgagee or convict seller 5/3 .
/—' /3
Address of Mortgagee or contract seller(number and street city.state.and ZIP code) Drawer N O 1/)
Name of assignee or other owner or holder of mortgage 02/0 U
Card NO.
Address of assignee(number and street nay,state.and ZIP.�cod/e/) ��' /V�-
Does aP nt pro m any atlxer If yes,what county? What Taxing District? • / D� -
county in Indiana? ❑ Yes No I I(a current year? ❑ Yes ❑ No I-
COUNTY AUDITOR
Deduction approved in the amount of
20 20 ,2/0 4 20 20 20 20
Signature Sig f— •
County Data(month,day,Sear)
I 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.
V �I(o7✓naze[e(o/wwneh M rfnre) mmbboo4 `��-/���J Q�//,1 Date(mwAlh,day,year)
/t/` Full resident address pp tit( r'frd sl t,ray,stales P ) ^�< 4 c-f
Person authorized by duly executed Power rttoAttorney or b j6-1.1-12-0.7 Z U -date(month,day,year)
I Address of authorized person (number and street c%slate,and ZIP code) •