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• '4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
"�¢ State Form 43709(R12/6-14) ''��^^11 I
° ,' Prescribed by Department of Local Government Finance A-{ II !. . �P
INSTRUCTIONS: g f r'•r
To be filed in person or by mail. Form filed with:
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. APR 2 7 ,•()yf,
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is "Ly Coun ty Auditor
located on or before January 5 of the immediately succeeding calendar year. • County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of th-I my a
where the property is located during the twelve(12)months before March 31 of each year the de uctio r, ,. +'+I r%f-ii
See reverse for additional i structions an qualifications. GIBSON COUNTY AUDITOR
Appli.cnt or contract buyer ry see resMc an reverse -•:
Y y �
Ta .ng eistny Key n mber/legal description Record number Page number
' id o -/3 73-description Oa/ Jo-oa 2 X700 L227
c.,� e• •-I property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
Mardi 1,".rrent 'ear March 1,current year date of application legal or equitable owner?
❑ 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: Is t property in question:Annually Assessed
Real Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract sell r(number and street, -, . d ZIP code)
Name of assignee or other owner or holder of mortgage "a-A-/e Address of assignee(number and street,city,state,and ZIP code) l �tSI ef x /6,,� /g Does applicant own property in any If yes,what county? What Taxing District? Has this dedu,,(•�7•eenregqested If yes,state am nt of ductfon
in Inr county on current property.• /,l/t n
o Ier county ❑Yes ❑No onrprot eea . •Yes ❑No K,! /
A persan:c ontant aoH.m.thic darha tinn,uilacc.tha nnrcnn has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recd —-- ""-- ecorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR
Dec
Drawer NO (R.O.5....
20 20 20 20
Card NO. t43 .I
Sigr County Date(month,day,year)
_ 4'0,5:23 c. )s
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.
1 Signatulg(owner's full name) 1 Date(month,day,year)
Full resident address of applicant(number a stye t,city,state,and ZIP cot),
I\ )_--7 m . Ym11S \C OJ, f� •
' ma c,
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,city,state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000.