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- STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS county Township Year
- FOR DEDUCTION FROM ASSESSED VALUATION .
State Form 43709(R13/10-15) _
Prescribed by Department of Local Government Finance
FILE
INSTRUCTIONS:
To be filed in person or by marl Form toed with:
Wing Dates: 1) Real Property:Must be completed and dated in the calendar year for which the deduction is sought. 99������
Must be fried or postmarked with the CountyAuditor or County Recorder of the county where the property is DEC y 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 is See raver-side for additional instructions and qualifications. GIBSON COUNTY AUiiitn R
orconbact•• - -see 25triaiwis on m fl side)
T •-D' yKe number/ Record Page number
o?( -/ , -x'67- 060. / 17—del 7 i ae.C‘C
as of I Mortgage l Contract indebtedness unpaid as of - Mortgage i Contact i died unpaid as of is the apprvant the sole
assumed year I as
assessment date,arrant year date of n 00 legal or equitable caner?
IC) ' ❑ Yes ❑ No
if no,what is his/her exact share of interest? If owned with someone other than cm q•,indicate with whom •
If name on record is different than that of applicant,indicate beim: �,I�ss property in question:Annually Assessed
• Real Property ❑ Mobile Horne Assessed,.,-n
Name of mortgagee or contract setter ��/`
lAddress of mortgagee or contract serer(num6vand street thy,state,and ZIP code) , r / / /
Sao ` f-\s �S Has this dedudmn been requested If yes,state amount of deduction
M current year? ❑Yes 0 N
A�' � T O -rson's mortgage or contract indebtedness that is recorded in the county
, ' 1 (� orgy recorders office)that is the basis for the deduction.
l C \�!h,l�C u \ ,C W . UDITOR "
(,_ l.�_ k� 20 20 20
C y Doe(mordh,Oar Year)a true and cod and that the applicant is a resident of Indiarw and
ed.
4 /w//n-/� Date(month,day,year)
Date(month,day,year)
Address of authorized person (numoeranosae=ovrr-:.a.,. . ___
The penalties for perjury can include imprisonment up to two and a half years and a fine not to exceed$10,000. _ ___ - -