Mortgage_Speicher 1
��.a_ . STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS bCouhtY Township Year
0�FF,`;��ggg'dff FOR DEDUCTION FROM ASSESSED VALUAT �-^�
State Form 43709(R11/6-09) J
Pr scribed by Department of Local Goremment Finance 1B ! H�"1!
File Mark
INSTRUCTIONS: ((��[�((`` 17��pp ,�(f�1'�aa
To be filed in person or by mail with the County Auditor or County Recorder of the countJh4h'erefnefpmpJay is located. Fain Wed
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 ring the ve (12 nths Court
before March 31 of each year the deduction i sought ,l 1L.. � N Recorder
See reverse side for Gq°(Ia ill iinn/e
s�huctionsa lifications. GIBSON COUNTY AUDITOR
APf nt(owner or�—/, Cl e
Ta r' i Key number/ al desaialon I Record number Page number
I l A cal/ lo- /3-id-300-00o.388-a-e �3 +IOS4t
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the appOrant the sole
March 1,current year March 1,atrirfq yeprpoo date of apptaation legal or equitable owner?
�l//y✓J I ❑ Yes ❑ No
H no,what is his I her exact share of interest? If owned with someone other than spouse;indicate with whom
If name on ream is different than that of applicant,Indicate below: is the
Property in question:Annually Assessed
❑Reel Property ❑Annually Assessed
I Mobile Horne(IC 6-1.1-7)
Name of mortgagee or contract seller
Jam
—Address of mortgagee or contract seller(number a..+ -7,state,and ZIP code)
jp F e r, morel ii-co E
5)
DEED y
1
a.n. t r1.6 Gi, at county? , What Taxing District? Has this deduction been requested on property
IC(-+�r for current year? ❑ Yes
❑ No
IU I 05q COUNTY AUDITOR•
_, -__..we amountot
20 20 20 20 20 20 20
Signalured 1j County 1 Date(month,day,year)
I/We certify under the penalty of perjury and foregoing information is true and coned and that the applicant is a resident of Indiana and
owner/contractt buyer of the aforementioned property on date application is filed.
na�� Loa I
Date(month,day,year)
Full resident address of a t(number and sane slate,and LP code)
40 10710 . 50 S r Oa (Rid G'{- Tr)/ '176b0
Person authorized by duty executed Power of Attorney or by IC 6-1.1-170.7 Date(month,day,year)
Address of authorized person (number and street,dry,state,and ZIP code)