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e•t STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun Township Year
FOR DEDUCTION FROM ASSESSED VALUATION -
State Form 43709(R12/6-14)�; Prescribed by Department of Local Government Finance —_ _ ;• ! , ■
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INSTRUCTIONS: i t r l
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. ��II
Must be filed or postmarked with the County Auditor or County Recorder of the county where the pro •is]. 7 21 j D-r 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 county
where the property is located during the twelve(12)months before March 31 of each year the deduction - south• 4 :;
See reverse side for additional instructions and qualifications. J • "l1�0•
Applicant(owner or contract buyer eerestd so�n�reverse side) GIBSON COUNTY AUDITOR
Taxing District (r Key nu ber/legal deU s Record n ber Page number
A 4„-//- a o - yap - 0 6Y• S! a -o J.-/ l.5 508k4
Assessed va of real 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?
(,01000 ❑ Yes Ili 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 roperty in question:Annually Assessed
eal Property ❑ Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller 41
•Address of mortgagee or contract seller number and and street, and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,and ZIP code) j n-'U� J��� J(�u
Pr 5 1-c - a - r I 1 o Pr C_ RA pp(( `730 1�
Does applicant own property in any If yes,what county? What Taxing District? Ha 15 - 5O(J l )
other county on / .�
in Indiana? ❑Yes ❑No all ( 1 U�s
!lILLLUIIfIIII
A person is not entitled to this deduction unless the person has a balance on the person's m 1 ty
recorder's office(including any home equity line of credit that is recorded in the county recor
COUNTY AUDITOR
Deduction approved in the amount of:
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 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-
Signatur owner' full name) Date(month,day,year)
_L—Th.
resident d of a ricant(number and street,city,state,and ZIP code)
i
Person authorized by duly 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) fir-.
The penalties for perjury can include imprisonment up to tw,and a half years and a fine not to exceed S10,000. p I g T n i
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