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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
bFOR DEDUCTION FROM ASSESSED VALUATION g
State Form 43769(Ri I/6-09) ®�.,./'1 I E ®�\y
Prescribed by Department of Local Government Finance JL lLJ A/
INSTRUCTIONS: F
To be filed in person or by mail with the County Auditor or County Recorder of the county where the property is located. U C t, : 2013
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 Properly Must file during the twelve(12)months
before March 31 of each year the deduction is sought. - C ^ 6der
lnIt
See reverse side for additional instructions and qualifications. GIBSON cm!INTYA IT
Appfian (owner m contract tract buyer-see restrictions on rare /side) sciernic, I AUDITOR
Taxing District Key number/legal description Record number Page number .
cb - 17-//- 2-061 - 6°I A5° - °)' 1 ao/,3 560.`/-3
Assessed of real , as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the apparant the sole
March 1,anent year March 1,cement year n date of application legal or equitable owner?
/ y9000 I Elves ❑ 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 different than that of applicant,indicate below:
Drawer Name of mortgagee or contract seller �/� (' O• ....... ...
Address of mortgagee or contract seller(n r and street,city.state.and ZIP code) Card rd N O. 5(eq S
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,slate,and ZIP code
P✓ N(� NE // - 3 -/07- I. 59 AC I
Does applicant own property in any other If yes,what county? What Taxing District? Has this deduction been requested on property
county in Indiana? for current year?
❑ ❑ No Yes ❑ Yes ❑ No
I
• COUNTY AUDITOR
Deduction approved in the amount of
20 20 20 20 20 120 20
Situ County
gna r 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. I
vy Signature(owners NO name) Date(month,day,year)
P .Ci ail aArtI h .L bcro I /x-9-1_3
Full resident of a t(number and street city,state,and ZIP code)
X dent ad
-KA (x) .ch+e ►Pcrc) l(65- Cw('newillr. irO 1/)(04,-
Person authorized by duly executed Pow of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street city.state,and ZIP code)