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`E.�._.-., STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
Co, FROM ASSESSED VALUATION
1`- " - Slate Form 43709(R11/6-09) I
��:RR='�''q9 Prescribed by Department of Local Govemment Finance
99JJ File Mark
INSTRUCTIONS:
b be filed in person or by mail with the County Auditor or County Recorder of the county where the,Aryperry r 1 Forth with:
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought. U t 1. 1 o r-V1 Rf 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 - I County Recorder
41
See reverse side foradd' nal instructions and qualifications. 4IMPt
Appluant(. 1 �il.La GIBSON I I i ►
I� ✓ r Key rwmberlle9aldescd , ` PieD y description 3 /
Assessed value
of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
Math 1,and year March 1, 77,7 date of application I legal o❑equY
If no,what is his/her exact share of interest? •// I If owned with someone other than spouse,i Indicate with whom
If name on record is different than that of applicant,indicate below: Is the property in question:Annually Assessed
❑Real Property ❑Annually Assessed
I Mobile Berne(IC 6-1.1-7)
Name of mortgagee or contract seller ` 1�//du/ilk/2 Address of mortgagee or contract seller(nukr and street�tede) I
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code)
Does applicant own property in any other If yes,what county? - What Taxing District? Has Nis deduction been requested on property
county in Indiana? ❑ Yes ❑ No for ou�m year? ❑ Yes
❑ No
COUNTY AUDITOR_ _ I
Dedud ion approved in the amount at
20 20 /20 /� 20 20 20 20
Signs W Audi r V ' '` ` / County t j y 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.
Signature(own tun name) I Date(month,day,year)
�riLe • .I C
f uA resident address of apprrant(number and street.a te,and ZIP code)
,' V S /laer iv itchwe „i f V16 7o
,s
Person au by duly
executed Power of Attorney or by IC 6-1.1-12-0.7 1 Date(month,day,year)
Address of authorized person (number and street,city,state,and ZIP code)