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` a STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION y!`
J State Form 43709(Rh /6-09)
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Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS:
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property 'is located. &I-
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Filing Dates: 1) Real Properly 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 4 s4 iti• •ecorder
See reverse side for additional instructions and qualifications. G I BSO N COUNTY AUDITOR
Appkant(•, - or it tract buyer-see - of reverse side) L (� (1�\
A b�� Al _ . .. •` •. a• U �lA�- .Y
Taxing D' � Key n bet/legal description Record number P e number
4� � oAt� Zb ^1b �b -a On fla O"1�}-oa ( jloR
valved property as of Mortgage 1 Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of ls the appfcont the sole
March current year March 1,cement year date of appacation legal or fade owner?
�"I aJ bj\d es ❑ No
If no,what is his/her exact share of interest? �v If owned with someone other than sparse,indicate with whom
If name on record is different than that of applicant,indicate below. ,Is Oq property in question:Annually Assessed
1—l1__•n—b•n•...I_1.Annually Assessed
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Name mortgagee or contract seller
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Address of mortgagee or contract seller(number and sweet city,state,and ZIP code) Drawer NO..Q3..I..3...
Name of assignee or other owner or holder of mortgage
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Card NO. it
Address of assignee(number and street,cdy.state,and ZIP code)
•
Does applicant own property in any other If yes,what county? . What Ta_._ 8
county in Indiana? ❑ Yes d ri I Mt CUITEIM year r al Yes U No
COUNTY AUDITOR
Deducton approved in the amount of. .
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/contract buyer of the aforementioned prrro!pee[)r_ttyy on date application is filed.
raw ( fW ) j'�.J-^i" • Date( ,day.year)
Oilres c of ap11p`��///lv��I(a////n///l(nu ��t.cirya'atate,and T(P lce'de))G1 5O // / _ . / v74
Person Pe"l/authorized by duly execoted Power of Attorney or by IC 6-1.1-12-0.7 ow / ...L/-/!V/ (-/j // Date(month,day,year)
Address of authorized person (number and street,city,state,and ZIP code) .