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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
,; FOR DEDUCTION FROM ASSESSED VALUATION
Tt State Form 43709(RI1/6-09)
Prescribed by Department of Local Government Finance h
INSTRUCTIONS: F, f,)
Form tied with
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is locatedr 2 �O,_Linty
Filing Dates: 1) Real Properly:Must file during the year for which the deduction is sought. S E P 2 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 - Sag----
See Recorder
See reverse side for additional instructions and qualifications. Fi°G�71C
Appf nt(owner or contract buyer-see ' . on reverseside) • GIBSON COUNTY AUDITOR
Ta istict • L/C.JI �n tuber/legal desoip4on Record number Page number
/ c_-c —' a(p -/a -07 - S101- coo. e.3 /- o at8 / 3 43E7S
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract Indebtedness unpaid as of is the applicant the sale
March 1.anent year Mardi 1.current year data of application legal or equitable owner?
5 crl ?00 b ❑ 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 ❑Annually Assessed
Mobile Home(ICs-1.1-7) .
Name of mortgagee or contract seller L _ `
Address of mortgagee or contract seller(number and street,city,state,and ZIP code) ,
Name of assignee or other owner or holder of mortgage _ ---C --
•
Address of assignee(number and street,city,state,and ZIP code) "OAP SO~ m P
jakiVALCA
Does applicant own property in any other If yes,what county? • What Taxing C n
county in Indiana? CI yes 2
J
❑ No /�`4
lo
COUNTY AUDITOR
Deduction approved In the amount of:
20 20 20 20 20_ 20 20
Sgna re County Date(month,day,year)
I/We certify under the penalty of perjury that the above and foregoing information is true and coned and that the applicant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed.
Sy name) i / Date(month,day,year)
a
resident
address of applicant(number and street,city,state,and Zle code)
3?o S. cemimtr y c /•ywce 744) tN f17770
Person authorized by dray executed Powerpfi Attorney or by IC 6-1.1-12-03 Date(month,day,year)
Address of authorized person (number and sweet,city,state,and ZIP code)