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rr.�o STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
i ; FOR DEDUCTION FROM ASSESSED VALUATION
./ State Form 43709(R12/6-14)
� / Prescribed by Department of Local Government Finance
INSTRUCTIONS:
FIL, F, I ) File Mark
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 whitiA//t�q��,d uctiontsought.
Must be filed or postmarked with the County Auditor or County Recorder ofyl/1bico my 1GI461-4 the property is X County 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 wit a cou A it he county
where the properly is located during the twelve(12)months before March 3 deduction is sought.
See reverse side for additional instructions and qualifications. • GIBSON COUNTY AUDITOR
Applicant co tract bu r-see spn/everse side)
Taxi pistil*7 KeyR u�be/rr/�ve,nal descriptio Record number Page number
Of ,�Q,tiC�, al�o-7 g--�3 Q3- coo. �ot3-c &, 02_0 ii 3748
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mort e/Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,current year dateIgp ic3hp� _O legal or equitable owner?
�� ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone(,her than spouse,indicate with whom
If name on record is different than that of applicant-inA'-- Is the property in question:Annually Assessed
❑ Real Property ❑ Annually Assessed
0I!Y 1 J Mobile Home(IC 6-1.1-7)
Name c" r lJ�'�
Address v ISO.—2 ••''....• 'code)
0v co'c` 3ng8
Name of a; 1
Address of a. Cal „afore,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes No current year? ❑
III Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity line of credit that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR
Deduction approved in the amount of:
20 20 20 20 20 20_ 20
Signature of•• I Auditor •
,. / County Date(month, ,y=.
-1. L4 . m _ / 4 •i__Allt4_fit
I e 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 I contract buyer of the aforementioned property on date application is filed.
Signature(o of full name)
'��(,y r� t�(1Q�j1 L,j/ Date(month,day,year)
ull rest entr'd , i�( u ber d st 4. at te.=rid ZIP code)
' l �f `� ,Q r4,,ch r TAI �t 7c,U�
Person authorized by duly executed Power of Aiorney 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 510,000. .