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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township I Year
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1:' FOR DEDUCTION FROM ASSESSED VALUATI IL
t f State Farts 43709(R11/6-09)
Presaibed by Department of Local Government Finance
File Mark
INSTRUCTIONS: �[(`
To be tiled in person or by mail with the County Auditor or County Recorder of the county U ek tl�)frrfpL+ is located. Form filed with:
Filing Dates: 1) Real Property Must file during the year for which the deduction is sought. r County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property Must file ' g the e 1 the
before March 31 of each year the deduction is sought County Recorder
See reverse side for additional instructions and qualifications. GIBSON COUNTY AUDITOR
N 1(owner or contractbuyer-see([¢ ,_ors on rave
sidy
�/.>7 • ( mbe/l escri
Ta 'rg ' trhct � number/leg esaipt&o Renard number Page number
A I a�-ZO -L3I -ye0 a �a - ! a0/`-f J .-5
Assessed yak*of real property as of Mortgage/Contraa indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the applicant the sole
Mann 1.current year March 1Wwent year date of application legal or equitable owner?
'I)/ 3cc ❑ Yes 10 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 Is the property in question:Annually Assessed
Weal Property ❑Annually Assessed
• - Mobile Home QC 6-1.1-7)
Name of ee or contract seller - -
g7.7,n4 1
Address of mortgagee or contract se er(number and street,bay,state,and ZIP code) ____.”..---_ - _ '
-
Name of assignee or other owner or holder of mortgage D ra ivCr NO
Address of assignee(number and street,city,state,and ZIP code) f
Card NO
Ds applicant own property in any other If yes,what county? • WI_ •• •.
oe • ;poly
county in Indiana? al yes El No • •• f No
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20_ 20
Signature of County Auditor County 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/contract buyer of the aforementioned property on date application is filed.
n"ature�(owrreYs ru0 reme) / ��fbrC-' /// Date(month,day.year)
/V`
Full resident` )nn/ ofayp a`n��-o'�n�u'mi.. a2� state,and
"ens 103
autlp�d� by dt%exewted Power o�ey�by IC fiY1-12-0.�� 19 ���/� Date(rtanN,day,year)
•
Address of authorized person (number and street,City,state,and ZIP code) .