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a, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
'1.,...Z State Form 43709(R11/6-09) F I L E..„.P
CI"/ Prescnbed by Department of Local Government Finance
INSTRUCTIONS: I File Mark
I)be filed in person or by mail with the County Auditor or County Recorder of the county where the property is locaticEB 3 'EOM'
Filing Dates: 1) Real Property:Must file during the year for which the deduction is sought I 0 County Auditor
2) Mobile/Manufactured Homes not assessed as Real Property:Must Re during the twelve 02)11)011 .
before March 31 of each year the deduction is sought unty Recorder
See reverse side for additional instructions and qualifications. GIBSONI COUNTY AUDITOR
Applicant(raw or contract buyer-see re • •ns on reverse side)
1714,--dta,-- C 4 1
, Record number Page number
IS istrict Kt5 nattier)legal desttion_3 0 0 _oo a. 5(0_0 otv
; 013 loctxy
value of real property as of Mortgage/Gonna indebtedness unpaid as of Mortgage!Contract indebtednesi unpaid as of Is the applicant the sole
Morelli.current year March 1,artrentirear. date of aPPrIcatial legal or equitable owner?
5 01, o o b 1 D Yes 0 No
If no.what is his/her exact sham of interest? If owned with someone other than spouse,indicate with whom
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If name on record is different than that of applicant.indicate below: is the PioPerty in question:Annually Assessed
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0 Real Property 0 Annually Assessed
I Mobile Horne(IC 6-1.1-7)
Name of mortgagee or contract seller zi
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Address of mortgagee or contract setter(number and steel,oily St3b3,and ZIP code) 1
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Name of assignee or other owner or holder of mortgage ,
Drawer No.. 45
Address of asegnee(number and street,city.state.and VP cede)
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Does applicant own property in any other If yes,what county? • What Taiing Distrit .
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couray in Indiana? Dyes 0 No cardNa OV(:).7/77 • I
COUNTY AUDITOR
Deduction approved in the amount at
20 20 zo 20 20 ix)
I 20
Signe r..- of . .ty Auditor - . • County 1 Date(month,day,year)
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I/We certify under the penalty of perjury that the above and foregoing information is true and correct and that the eppficant is a resident of Indiana and
owner/contract buyer of the aforementioned property on date application is filed. I
(ovmer's fut/risme) 1 Date(month,day,year)
N.Nt.e. ?::11c-NiNi-t.S) .
'Fub resident address of applicant number and sireet,city state,and ZIP code) I
- ‘ k•OC)I 1.".) 0 int3*.ar VVM‘‘0 L.A._) k\C-1.00 -xtkark-k %AN.) 47th 37)
Person authorized by duty executed Power of Allomey or by IC 6-1.1-12-0.7 1 Date(month,day year)
Address of authatted person (number and street,city state,and ZIP code) . 1
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