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5" STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
r'°e` s FOR DEDUCTION FROM ASSESSED VALUATION
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-.) 7--, State Form 43709(R12/6-14)
�' Prescribed by Department of Local Government Finance
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INSTRUCTIONS: ITgI T , File Mark
To be filed in person or by mail. A 1 ', 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 filed or postmarked with the County Auditor or County Recorder oft¢ecoynty win the property is aunty Auditor
' located on or before January 5 of the immediately succeeding calendar ye r 1 4 LU 1 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 each ye r th etion is sought.
See reverse side for additional instructions and qualifications. Pr
Applicant(owneror tr$ct buyer see s'✓i on reverse sir ) GIBSON COUNTY AUDITOR
hg is (l'i7V AJ1 Key num,`berr'/J/llegal description Re rd number Page number
WO- - ,—acs-- , s-1 1 -ca.-) 7s 3rt23
Assessed value of real sty as of Mortgage/ ct indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
r
March 1,current year March 1,cu / date of application legal or equitable owner?
�VV r) ❑ 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 6-1.1-7)
Name of mortgagee or contract seller //{��/"�/��
Address of mortgagee or contract seller(num an et,city,sta) ,and LP ri )
Name of a 13 u (Q J ` I I Npp I�.`/1-/v,G
Address of RCA/AL 1/1-ria)
Does applit h/ .3 bi cpD' listrict? Has this deduction been requested If yes,state amount of deduction
other count /V 161 on property for
in Indiana? cement year? ❑Yes ❑No
A person is _ _n the person's mortgage or contract indebtedness that is recorded in the county
recorder's t _ , ____ _.,.,,,r nnc ur 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
Signet e f County Audito�r oQ � County Date(month,day,year)
1�d
on 11— WCIca
I/We certify under the penalty of perjury that thetabove and foregoing information is true and correct and that the applicant is a resident of Indiana and
owner/contract buyer of the afore tioned property on date application is filed.
&Al.1Sig_n ffullname)) (/� Date(month,day,year)
sident a of applicant�v U ( umber and pet,city,state, d ZIP code)
rI 47 ` car AV b 1 (n cn c y� 1-19{0>6
Person authorized by duly executed Powe 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.