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o—'W STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
4 a{ FOR DEDUCTION FROM ASSESSED VALUATION
11 o,, ,/' State Form 43709(RU/6-09)
. \ % Prescribed by Department of Local Government Finance
File Mark
INSTRUCTIONS:
To be filed in person or by mail. T tri Llid
Filing Oates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction i oug . $ I )
Must be filed with the County Auditor or County Recorder of the county where the property is located ` aunty Auditor
on or before January 5 of the immediately succeeding calendar year. n ❑ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Properly:Must file with the County Auditor�4W 3 _2015
county where the properly is located during the twelve(12)months before March 31 of each year the
deduction is sought. n'
See reverse side for additional instructions and qualifications. J/t,_.1 -1..�F��
Applicant(owner or contract buyer-see restrictions on reverse side) GIBSON COUNTY UNTY A UDITOR
Troy D. Fortune AUDITOR
Taxing District Key number/legal description p '/ Record number Page number
Johnson 02416-jJ Ja0 ad„?.G/i'- a V I�p-4(M r7
Assessed value of real property as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
March 1,current year March 1,current year date of application legal or equitable owner?
5227,190.00 IS 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
Ti Real Property ❑Annually Assessed
Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller
First Financial Bank NA
Address of mortgagee or contract seller(number and street,city,state,and ZIP code)
1 Mortgage Way, Mount Laurel, NJ 08054
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,stale,and ZIP code)
Does applicant own properly in any other If yes,what county? What Taxing District? Has this deduction been requested on property
county in Indiana? for current year?
❑ yes Ti No ❑ yes 0 No
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.
Signature(owners /I n e Date(month,day,year)
Full res' ent address of applicant(number and street,city,state,and ZIP code)
1812 E 1200 S, Haubsiadt, IN 47639
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)