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n'.4 STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R12/6-14) •
'�-�4 Prescribed by Department of Local Government Finance T L
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ED,
JIJIi RFoOnrd .th:
INSTRUCTIONS:
To be filed in person or by mail.
Filing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought.
Must be filed or postmarked with the County Auditor or County Recorder of the county where the properp115. El County Auditor
located on or before January 5 of the immediately succeeding calendar year. FHi UU II]] 14 2015 County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the property is located during the twelve(12)months before March 31 of each year the deduction i ught.
See reverse side for additional instructions and qualifications.
r
Applicant(owner or contract buyer-see re frictions on reverse side)) GIBSON COUNTY AUDITOR
- _ - -- -
T District a Key number l llegalldeescd pt n
Record number Page number
A6,-06 -33 -300 - 00 3 . 88/ - v .1 ) aotc 1 )-63
Assessed value of real property of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,anent year March 1,current year date of application legal or equitable owner?
. 10( 5 0 0 ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone o&er than spouse,indicate with whom
If name on record is different than that of applicant,indicate below: Is the property in question:Annually Assa4sed
❑ Real Property ❑ Annually Assessed
\ Mobile Home(IC 6-1.1-7)
Name of coo agee or contact seller ( _ /
Address of mortgagee or co ct seller(number and street,city,state,and ZIP code) //'�~r///Jry/•
•
Name of assignee or other owner or holder of mortgage
Addrrss of assignee(number and street,city,state,and ZIP code)._
T Spate 33 / to Jl O �� ��
Does applicant own property in any If yes,what county? What Taxing District? F
other county c Dha1Ye1' NO
in Indiana? ❑Yes ❑No c
A person is not entitled to this deduction unless the person has a balance on the person's � V
recorder's office(including any home equity line of credit that is recorded in the county roc Ca rd NO. .... ,.^/ 1, c S..
COUNTY AUDITOE
Deduction approved in the amount of:
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20 20 20 20 20 20 20
Signature of County Auditor / County Date(month,day,year)
(
I/We certify under the penalty of perjury that the above d 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.
" Si� � wnef fullname) Date(month,day,year)
(X1-1
Full resident address of applicant(number and street,city,state,and ZIP code)
Ix• 2087 p3 . cs 2 (Nuts Pers-JcCz..) w 47Q73
Person authorized by duty 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 510,000.