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STATEMENT OF MORTGAGE OR CONTRACT I unty Township Year
l FOR DEDUCTION FROM ASSESSED VALUATI E
-s...- State Form 43709(R11/6-09) 1 D
Prescribed by Department of Local Government Finance
INSTRUCTIONS:
JUN 17 2013 File Mark
Tp be filed in person or by mad with the County Auditor or County Recorder of the county where the properly Forth road w
Filing Dates: 1) Real Property:Must file during the ty p �� located
ng year for which the deduction is sough County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property:Must Me 2)months
before March 31 of each year the deduction is sought G I B S O N COUNTY AUDITOR County Recorder
See reverse side ,.r additional instructions and qualifications.
AppGant(mane b on reverse side)
` '/��/.}�_,I oo�.r���/t//�,,�. w 0245,—W�s,900(c/- OO ��Q/tf
Tad //�-•)number/ •..(��plJ )3-n-303-00o. 35 8-�. dnum�( Ur l�
Assessed value of real property aeayjof Mortgage/Contra indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,arm i year Marts 1, data of application legal or equitable owner?
030,0 ❑ 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 ❑Amu:illy Assessed
/ Moble None QC 6-1.1-7)
Name of mortgagee or contract seller Uoi — �/�L/- / 07/ 7 8�
Address of mortgagee or contract seller(number and.street city:sta:o,and LP code) l//-Tr �-/-
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 ❑ No ❑ yes ❑ No
COUNTY AUDITOR .
Deduebon approved In the amount of
20 20 20 20 20 20_ 20
•
Signature of County Auditor Signature County Date(month,day,year)
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 I contract buyer of the aforementioned property on date application is filed.
�kJpp (owner's tuft nam Date(month,day,year)
Full resident address of appGmlt(number and street,ray,state,and ZIP code)
CO 41), N \�-r(1v:sudrmsfi Vnus.uaco Zit LI--7 (.t4°)
Person authored by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number end street city state,and ZIP code) •