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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
: : FOR DEDUCTION FROM ASSESSED VALUATION
-" f'. State Form 43709(R11/6-09)
•'-a`:::- Prescribed by Department of Local Government Finance
INSTRUCTIONS: �qvn{�
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located. J[(' :20,3
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought [] County Auditor
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 u^
See reverse side for additional instructions and qualifications. GIBSON COUNTY AUDITOR
Ap owner or contract buyer-see an reverse side)
Taxing Disbict number/legal 'Minn Rem nun°� Page nun
alo- io - 3/0- 10/- 000 . 48 '7-o /J / P
Assessed of real , as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract Indebtedness pail as of Is the app�t the sole
March 1,current year March 1,anent yea sate of apPrrcaticn legal or equitable owner?
A5 834 0 Yes 0 No
If no,what is his/her exact share of interest? If owned with someone other than space,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(IC 6-1.1-7)
Name of mortgagee or contract setter r
P �p6 siii,e- _ _=_s /�./..._
Address of mortgagee or contract seller(number and street,fr,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street thy,state,and ZIP code)
Does applicant awn property in any other If yes,what county? - What Taxing District? Has this deduction been requested on property
county in Indiana? ❑ Yes ❑ No for current year? ❑ Yes ❑ No
COUNTY AUDIT( Drawer Na.,Q�� �3..,.,
Deducton approved the amount of:
•
20 20 20 20 Card NO. � ...
Signature N2J✓ty'LCd !H''r-�.'�!/� Count) - -
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/contract buyer of the aforementioned property on date application is filed.
Signature( h ) Date(month,day,year)
r
Fug nl ad L C3 of apP umbeita Ssbeet/tiry,Ire,and ZIP code) r , y 'ice ea-5
authorized S by duly executed Power of Attorney or by IC 6-11.1-12-0.7 Date(month,day.year)
Address of authorized person (number and street city,state,and ZIP code) .