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axQt STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
'= State Forth 43709(813110-15) FILED
Prescribed by Department of Local Government Finance
INSTRUCTIONS:
To be filed in person or by mail. fled with:
FiIhig Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction Is sought DEC ..1 If.
Must be filed or postmarked with the County Auditor or County Recorder of the courtly where the property is. r County Auditor ,
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Property.Must file with the County Auditor of r e;449
1 t•I My Recorder
where the property is located during the twelve(12)months before Martin 31 of each year the dad :' �•� I.r -
See reverse side for additional instructions and qualifications. GIBSON COUNTY AUDITOR •
AppOpnt( Wryer mfyicfians on re eiei
Taxing D' 11 a,j Record
- cow. i{so•oa 8' l - So?3
Assessed value of real pmperty as of 1 Mortgage r Contract indebtedness unpaid as of • Mortgage r Contract indebtedness unpaid as of Is the applicant the sole
assessment data amend year I assessment date,°meat year date of application legal or equitable owner?
OD( 0157-) ❑ yes ❑ No
If no,what is his I 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 belay Is the property In question:Annually Assessed
❑ Real Property ❑ Armuafly Assessed
Mobae Home(IC 6-1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(number and street thy,state,and ZIP code)
Name of assignee or other owner or holder of mortgage '
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Address of assignee(number and street aIy,state,and ZIP code)
Does applicant own property in any N yes.what county? - ` `, �l.� Nested If yes,slate amount of deduction
otter nty in clan ? ❑Yes ❑No 0 0.� No
A person is not entitled to this deduction unless the peroo iebtedness that is recorded in the county •
recorder's office(including any home egtaiy fine of aedit; I b— S 013 1 basis for the deduction.
Deduction approved in the amount at
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20 20 20 20 20 20 20
Signabne of County Auditor County Date(month,day,year) '
I I 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/contract buyer of the aforementioned property on date application is filed.
Signahrreut name) Date(month,day,year)
Full resident address of applicant(number and street,city,state,and ZIP code)
9OY S. Adams S-E. P%Na/on// r/✓ y 76 7(`7
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 (marker and street ay.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.