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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
to,; FOR DEDUCTION FROM ASSESSED VALUATION
t Slate Form 43709(RN/6-09)
I
Prescribed by Department of Local Government Finance
INSTRUCTIONS:
b be filed in person or by mail with the CountyAuditor or County Recorder of the county where the property is located.)
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought. I ❑ County Auditor
2)Mobile/Manufactured Homes not assessed as Real Property:Must file during the twelve(12)month()C T 2 3[2043ounty Recorder
before March 31 of each year the deduction is sought LLN
See reverse side for additional instructions and qualifications.
Ap I(owner or contract buyer- z side)
GIBSON COUNTY Au ITOR
Ta " District - Key number/legal description Record
num P re n/
� �a - l4- l9 - 203 - coo. D87 - 006 616/0
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
• March 1,anent year March 1,current year. �[ date of application legal or equitable owner!
37 000 ❑ Yes ID No
If no,what a his I 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
p Real Property ❑Annually Assessed
- I Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller - _ I
•
Address of mortgagee or contract seller(number and street city, ,and ZIP code) '[� /3 5 7&1
Name of assignee or other owner or holder of mortgage ` ^1l(��/jl C � •
Add pf assignee(number and sbee4 city,state,and ZIP code) �"q/ �M
l l 9 8 , 7 & ` .i 34f ccetc% .F-Rd e• U .
Does applicant own property in any other If yes,what county? • / on property
county in Indiana? ❑ Yes
❑ No I I U Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount at I
20 20 20 20 20 20 20
Signora ofi'( , ' County I 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.
XSigne (owners name) Date(month,day,year)
ont of applicant(number and strae4 city,stare,and ZIP code)I7 5 6 $ 1 E Dc Al ir.6/ c�4, , yXl 121"76(0 x 6o
Person authorised by duty executed Power of Atto/ney or by IC 61.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street,city,state,and ZIP code)