Mortgage_Neber STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R11/6-09)
• Pnesmbed by Department of Lod Government Finance
F p le
INSTRUCTIONS:
To be tiled in person or by mail with the Cou Auditor or County Recorder of the county where the property FSrrtffled"
Pa Y rdY h ty P Pent'is located.
Filing Dates: 1) Real Property Must Me during the year for which the deduction is sought. s P H _Cou 1ty Auditor
2) Mobile/Manufactured Homes not ascresed as Real Property Must file during the twelve(12)months 4
before March 31 of each year the deduction is sought -rty Recorder
See reverse side far additional instructions and qualifications. �) n/ ��
..� . ormrmart fjrper'� qn reverse ' e) ( / /�ae GIBSOyN COUNTY AUDITOR
- tnn �f / mumbo Page i
�i rev c / —�� 7/ / 6VZ / a07 �� taet;-
Assessed value tired property as of I Mortgage/Contract Indebtedness unpaid as of Mortgage/Con btedness unpaid as of Is the applicant the sole
Math m year Mar 1;current I March 1,current yr date of cup legal or equitable owner?
a ❑ 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 apogean;Indicate below Is the property in question:Annuaaj Assessed
Real Property ❑Annually Assessed
• Motile Hare(IC 61.1-7)
Name of mortgagee or contract seller /QJ /) n
Address of mortgagee a contract seller(number and soplj4 cXy,staaattee,,and ZIP code r/�U
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP code)
____.. _.._ nty? • Flexing District? Has this deduction been requested on property
for anent year? ❑ Yes ❑ No
•Drawer NO aO
�
COUNTY AUDITOR
Card NO. /63`�j
20 20 20 20
•
County 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/contract buyer of the aforementioned property on date application is fled.
XSignature tamers fiA r9fte) Date(month,day,year)
X
Full resident address applicant(number and street,cal,state,end ZIP code)
J 1001 N, Halt 5-F ir;.iceibr1 976170 TivCa
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and street dry.state,and ZIP code)