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STATEMENT OF MORTGAGE OR CONTRACT INDEBTC S n Township Year I
`. FOR DEDUCTION FROM ASSESSED VALUATION k
State Form 43709(R77/6-09) .1\ V
Prescribed by Department of Local Government Finance 1,,
AUG 0 6 2013 File Mark
•STROCTIONS: Form filed with:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located.
Filing Dates: 1) Real Property:Must Me during the year for which the deduction is sought. 0 County Auditor
2)Mobile/Manufactured Homes not assessed as Real Properly:Must file during the
before March 31 of each year the deduction is sought
GIBSON COUNTY AUDITOR County Recorder
See reverse side for additional instructions and qualifications.
r (owner or ccontrary uy restrictions onre e) .
GO C T.iv '- I ` / Key number/ thin f �OX\ Record number Page number
•oltnrvtPlt a -1/c-19-k-int-I - ow599 oa (0 I a01 0? 951
Assessed -ue of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the applicant the sole
March 1,anent year March}y,(,q�r ent year date of application legal or equitable owner?
U 3 000 ❑ 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 afferent than that of applicant,indicate below Is the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
Mobile Home(1C 6-l.1-7)
Name of mortgagee or contract seuy -
Address of mortgagee or contract seller(number and street city,state,and ZIP code) � �)
Name of assignee or other owner or holder of mortgage Q.
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Address of assignee(number and street,coy,slate,and ZIP code) (^-ff(`�"q�tr.��,,,/.,•,...
"1
. Card \o
Does applicant own property in any other If yes,what county? • don property
county in Indiana? ❑ yes ❑ No
es ❑ No
COW' _._...cur(
Deduction approved in the amount ot.
20 20 20 20 20 20 20
Signature of County Auditor • 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.
grit:(omofs uircLi n Date(month,day,year)
F ent address f appfcant(number�and sbbeee4 ctesta and ZIP code)
M g E. (5-ic- S-t street ii, `i71,o V1
Person authorized by duly executed Power 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) •