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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Coun� t; Year
sr'.= '. FOR DEDUCTION FROM ASSESSED VALUATION
�' State Form 43709(R13/10-15) -i t. A
�- Prescribed by Department of Local Govemment Finance
INSTRUCTIONS: AU rEiI$Mars
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 filed orposbnarlred with the County Auditor or County Recorder of the county where the property 424641fitd urdy Auditor
located on or before January 5 of the immediately succeeding calendar year. GIBSON COI,NES'abtiltblfittoptder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the property is located ' the twelve(12)months before Marco 31 of each year the deduction is sought
See reverse side for addition • strudions and qu rificatrons.
owrrerwcontract see reverse ",- ea...00(70 Liza
e- f . i/
T-•: /' Record number Page mber
�o� , —76-7461 - 00 . 06,=5---0 a (21016 Ce
• _- value of real property as of Mortgage I Contact indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole •
-,-z'-- �-nt date,current year assessment date,current year date of legal or equitable owner?
0300 ❑ yes ❑ No
If no,what is his/her exact share of interest? It owned with someone other than spouse,indicate with whom
If name on record is deferent than that of applicant,indicate baby. Is property in question:Annually Assessed
Real Property ❑ AnnuallyAssessed
///``` Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller /S 1 t // ] /�
Address of mortgagee or contract seller(number and s#ee`t/dry, ,and ZIP coddee))/_/LY-mil /�f,(%,(-(yam(,-(��,
Name of assignee or other owner or holder of mortgage ��1I iA„ , ,? ,e, ,Address of assignee(number and street coy,state,and ZIP code) (i'L-(-r//�-1�Does applicant own property in arty If yes,what county? What Taxing District? Has this vested If yes,state amount of deduction
ty on for in Indiana? ❑Yes ❑No anent r? ❑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 Mated��� air- Mated in the county recorder's office)that is the basis for the deduction.3 COUNTY AUDITOR
Deductior
20_ I D 20 20 20 20
Signature I 19 -0146° Cowry - Date(month,day,year)
I l We certify under the penalty of perjury that the above and foregoing information is true and coned and that the applicant is a resident of Indiana and
owner!contrail buyer of the aforementioned property on date application is filed.
S' re(owners Time Data(month,day,year)
Full residf applicant(nu and sheet,c2y,state.and ZIP code)
1Aaa(0 S. RroZA_ i,—. A-cr_uLbSkcdt T( 4 3°t
Person authorized by duly executed Power of Attorney or by IC 6-1.1-12-0.7 I Date(month,day,year)
Address of authorized person (number and street,dry,state,and ZIP code)
The penalties for per)ury can include imprisonment up to Iwo and a half years and a fine not to exceed$10,000.