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M STATEMENT OF MORTGAGE OR CONTRA J County Township Year
p FOR DEDUCTION FROM ASSESSED VALIPrII NL
-_'!:4T-47- State Form 43709(R11/6-09)
Presaibed by Department of Local Government Finance
INSTRUCTIONS:
DEC 2 0 2013 File Mark
To be filed in person or by mail with the County Auditor or County Recorder of the to my where the • ••.r. ' located. Form filed with
Filing Dates: 1) Real Property Must file during the year for which the deduction is-• ei �1
2) Mobile/Manufactured Homes not assessed as Real Property M - p'" .".'�rltf.• -Ive 12 months '�-I County Auditor
before March 310 f each year the deduction issought GIBSON COUN YAUDITOR ❑ County Recorder
See reverse side for additional instructions and qualifications.
Apparent(owner or contract buyer-see restrictions on reverse vile)
reiNor .l e- Se inn alder-
Taring District Key number/legal description Record number Page number
ShnsoV\ L.-La-10- 36o 0'5 I , CI [ -Cia (-71 070/3 4)34fy
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage I Contact indebtedness unpaid as of Is the apprrcant the sole
March 1,ascent year March 1,corneal year
data of application legal or equitable owner?
/L5-000 ❑ Yes ❑ No
If no,what is his/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. tQIs property operty in question:Annually Assessed
1 ^ al Property ❑throaty Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract ler�.C.0 r�yl AI r
Address of mortgagee or contrail seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage --— _..
Address of assignee(number and street,city,state,and ZIP code) Drawer
Does applicant own property in any other If yes,what county? • What Taxing 0 NO a°l 3
county in Indiana?
❑ Yes ❑ No Jo
pf-- cSi io - 9 - if % oe 317
COUNTY COUNTY AUDITOR Card �O. ....5•Y
Deduction approved N the amount of 4 i 5itoo.
wv ./
20 20 20 20 20 20 20
Signature of County Mentor - Canty Date(month,day,year)
I 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 proif pererty ponnddaatteeJapplication is filed.
Slgaah ( MI name) E, jc "`� ! 7 �( •day,year)
uti resident s o pfoant(number and sheet city,state,and ZIP code)
". I/5-7 5- 5 0w -SvcsLr R4 Mite174 1* Tn- 476 ?
Person authorized by duly executed Power of Atbmey or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and sheet city state,and ZIP code)