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-,-., STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year State Form 43709(R12/6-14)
1 z FOR DEDUCTION FROM ASSESSED VALUATION •
'� �i Prescribed by Department of Local Government Finance ������p
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INSTRUCTIONS: Fil 11.F.Ti it
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. ae���
Must be filed or postmarked with the County Auditor or County Recorder of the county where the propeayusr 5 2015 u4U tt
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 with the County Auditor of the co my
where the property is located during the twelve(12)months before March 31 of each year the deduction'q lr vh�l 4�1a'
See reverse side for additional instructions and qualifications.
Applicant caner or contract buyer-see restrictions on reverse side) GIBSON COUNTY AUDITOR
Taxi ism Key number/legal d f tion Record number Page number
.ud g & -//- o/ - /oo -ao.3 . 7 �6 -o A , 2o' 5 3059
Assessed value of real p as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,current year date of application
01,375- egal or equitable owner)
• /S, 0 Q El 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 the property in question:Annually Assessed
❑ Real Property ❑ Annually Assessed
Mobile Home(IC 5-1.1-7)
Name of mortgagee nbact seller _
C 7 C C . u a U . - 7- ci, G 2/ t'- Qtr_
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code) / ` oz__- kJ (,J / , Z - //
ar
Does applicant own property in any If yes,what county? at Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes ❑No current year? Li 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 '^ 1 20 I 20
Signatu of
i'�E%Z�VV` / �Y/��/y� 1� County
I I We certify under the penalty of perjury that the above 2nd'foregoing information is true a OM J P-1 10 and
owner/contract buyer of the aforementioned property on date application is filed. - I
r lure(ow r full name) /
si enl add pplicant(number/ ,street ,state,and ZIP code) / (7 70
•
17y Obi / 11w 411- PA cC•� :tr - 177
Person authorized by duty executed Pcn er of Attorney or by I 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.