Mortgage_Mays 1` ., i STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS
CounFI Js Ip; Year
FOR DEDUCTION FROM ASSESSED VALUATION
f,-.1 'i4 State Form 43709(R12/6-14)
r Prescribed by Department of Local Government Finance Qder12015
INSTRUCTIONS:
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.
Must be tiled or postmarked with the County Auditor or County Recorder of the county where the property is ty Auditor
located on or before January 5 of the immediately succeeding calendar year. GIBSON COU YoNIAPIITGEtder
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 is sought
See reverse side for additional instructions and qualifications.
Applicant(owner or contract buyer-see restrictions on reverse side)
T ng District Key ber/legal description Record number Page number
Q c� � If3 b I06 - ( no:La S-O.1 as l5
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
Mardi 1,current year March 1kAurrent year date of application legal or equitable owner?
T a 1 I3 I �fes ❑ 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 belovr: s property in question:Annually Assessed
Weal Property ❑ Annually y Assessed 6-7.1-7)
1lName of mortgagee or contract seller •
Lei e o v� ,. - t X-mV
Addres of mortgagee contract seller(number and street,city,state,and ZIP code) — u
Name of assignee or other owner or holder of mortgage \/�\
all Address of assignee(number and street,city,state,and ZIP code) /-/ ‘C-1
�[�
Does applicant own property in any If yes,what county? What Taxing District? - J O� .�LLI -"Jul of deduction
other county C/ _ 0,.�]V//
in Indiana? ❑Yes 1.9 da Do
A person is not entitled to this Meduction unless the person has a balance on the pers �`)/4/ /� r my
recorder's office(including any home equity line of credit that is recorded in the county rec . lJ Jv/
COUNTY AUDITOR
Deduction approved in the amount of: / ' ,
20 20 20 20 20 20 IvAV/
Signature of County Auditor 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
owner/contract buyer of the aforementioned property on date application is filed.
Siigne re(owner's full name) Date(month,day,year)
Fu II ide t address of applicant umberand, city,state,and ZIP code)
165 avlfcr lrtKtc- Rd Pr(ntx+ONl2 J Y76/c
Person authorized by duly executed Power of Attomey 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.