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f� .i STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
if a FOR DEDUCTION FROM ASSESSED VALUATION
7`"'1-'' State Form 43709(R13110-15)
Presalbed by Department of Local Government Finance I
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INSTRUCTIONS:
IP fit
To be filed in person or by mail. Form filed with:
Filing g Dates 1) Real Property.Must be completed and dated in the calendar year for which the deduction is scO 4 2 9016 ❑ County Auditor
Must be filed orpostmarked with the County Auditor or County Recorder of the county where the pro rty i
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 Au the co
where the property is located during the twelve(12)months before March 31 of each year the -
See reverse side for additional instructions and qualifications. GIBSON COUNTY AUn ITOrt
Applicant( vner or contact buyer-see son reverse side)
-% Q/T
Taxing District Key nu /legal description Record number Page number
a6 . / 7 -01 - yoo —OOY. 713 —o1( / (n � a,-5
Assessed -• real property.=of Mortgage/Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment•-s,current year f assessment date,current year date of application legal or equitable owner?
5, `j 99 0 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 Horne(IC 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract serer(num and street " ,state,and ZIP code)
Nme a of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP code) 7/S �y/tyYt{�_�`�°�'�l�
Does applicant awn property in any If yes,what county? What Taxing District? /� - - eduction
other county
in Indiana? ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgy.,a _ ��� n the county
recorder's office(including any home equity line of credit that is recorded in the county recorder's office)ma..--
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 1 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 I contract buyer of the aforementioned property on date application is filed.
krSigna Da( name) Date(month,day,yeaf)
/Full resident address of applicant(number and street;#4,istate,and ZIP code)
798 w Soo 4 d'" Y7G6, s
Person authorized by duty executed Power of Attorney or by IC 61.1-1203 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. g