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R DU STATEMENT IO F MORTGAGE ES OR CONTRACT INDEBTEDNESS CounF s pear
mss:: FOR DEDUCTION FROM ASSESSED VALUATION
: j" t' State Form 43709(R11/6-09)
r`R'- Prescribed by Department of Local Government Finance
INSTRUCT7ONS: $ Y!2013
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: I) Real Property:Must file during the year for which the deduction is sought. I _b tMli( ditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)months
before March 31 of each year the deduction is sought. - GIBS•N e s a '15 SR
See reverse i for additional instructions and qualifications.
Appfrant(. - ormnuacr buyer- --. :..,on reverse
a'_ _/I.... I t1� I ' 4 /
x /ien.d.-.Lion - Remm number Page number
A • - value of real property as of Mort gage!Contract Indebtedness unpaid as of Mortgage/Contract Indebtedness unpaid as Is the appalant the sole
March 1,current year March 1,current year date of application , f legal or equitable owner?
/5 flO6. Y O ❑ 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 deferent than that of appecant.indicate below. \Is the property in question:Annually Assessed
. `{(I Real Property ❑Mobile 6-1.1-7)
Name of mortgagee or contract seller /"l /( �1n A - // // • /�
Address of mortgagee or contract seller(number and street city.state.and ZIP code)
( IN
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,c%state,and ZIP code)
Does applicant own property in any other If yes,what county? • What Taring District? Has this deduction been requested on property
county in Indiana? ❑ Yes ❑ No for current year? ❑ Yes ❑ No
CC ,I'
o
Deduction approved in the amount of: /R\ 7
Drasver'NO' JO� - _
20 20 20 20
Card NO. ft.O`1/L-
Synature of County Auditor ry,Year)
I/We certify under the penalty of perjury that the above and foregoing information is true anti curets:Wa n.w........,.,__... - ..'dent of Indiana and
owner I contract buyer of the aforementioned property on date application is filed. _
Sig (owwnneerr's fig name) I ��SQ, ,(T Date(month,day.year)
Full resident address of a t(piumber andstree`t gjgt state,and ZIP code)
1\ 0Li 1 E 15-0 3 . -. rain TN "V7io`IO
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-03 Date(month,day,year)
Address of auaa ice l person (number and street city.state,and ZIP code) .