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.ate. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
;4 FOR DEDUCTION FROM ASSESSED VALUATION FIT- State Fona 43709(R11/6-09) p .,
'y o Prescribed by Department of t�l Government Finance 1i �t E I711
File Mark
INSTRUCTIONS: 2 b be Ned in person or mail with the County Auditor or County Recorder of the county where the "'CU'r vAtir
Pe by N h b properly is loco
Filing Dates: 1) Real Property.Must file during the year for which the deduction is sought ❑ County Auditor
2)Mobile/Manufactured Homes not assessed as Real Property Must file during the twelve(12)monpl6 . County Recorder
before March 31 of each year the deduction is sought )J�IL,
See reverse/// ddda for additional instructions and qualifications. GIBSON COUr4 FY AUDITOR -
APprnarmlor V on reverse side)
Taxi ist st Key number/legal description Record number Page number
A 47 -/3 - i3 - 3 o0 - coo. J44 -00 4 , 9 O& 3 4 7
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the appOmnt the sae
March 1;current year MMaarrrdhi 1,arrant year date of aPPGntimm legs a equitable owner?
/a SOD Yes 0 N
If no,what's his I her exact share d 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
❑Real Property ❑/wwallyAssessed
• Mobile Home QC 6-1.1-7)
Flame of mortgagee a contract seller
F c (__ -!-
Address of mortgagee or contract seller(number and street,coy,state,and ZIP code) _/._(J/(/�.��/�`�(/,�y\//�
-
Name a assignee or other owner or holder a mortgage Drawer N
•
O . 1 }/)t(�
Address assignee rand S state,a� code) - 9 ca- 4- C Card NO. 35 T
Does applicant own property in any other If yes,what county? - What Taxing District?
county in Indiana? ❑ Yes ❑ No
COUNTY AUDITOR
Deduction approved in the amount of.
20 20 20 20 20 20 • 20
Signs jt 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
r I contract buyer of the aforementioned property on date application is filed.
XSig hi (owners noire) Date(month,day,year)
_per a � _ � /� r1 of nT [�J
Full resident ben��r�.r--r'7�U L�code)
,—I—/U / /f�r!/(/ .
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12a7 J/ Date(math,day,year)
Address of authorized person (number and street,city,state.and ZIP code) .