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rt.. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
�' '-'‘ FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43769(R13I 10.15) ;y-
Prescribed by Department of Local Government Finance
INSTRUCTIONS: F J Ile),,Erin. ►o.
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To be filed in person mail. �=`
Fifng Dates: 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought. nnn
Must be tiled orposfmarfced with the County Auditor or County Recorder of the county share the properbti�r s H'�nty'Auditor
located on or before January 5 of the immediately succeeding calendar year. 1111[C 1. nTy
2) Mobile/Manufactured Homes not assessed as Real Property. Must file wart the County Auditor of the county Recorder
where the property is boated during the twelve(12)months before Mardi 31 of each year the deduction is�y§/ught
See reverse side for additional instructions and qualifications. T+� grn7%ii
Applicant • ` o r contract ewer-see restia'w'son reverse side) - r GIB,.ON #if ND!'AUDITOR
°F �rr .. o_t r./ a .: C
Taxing • �.1 Key number t legal description .// _•...number Page number
• q6— /07- 07 /yOfQnr� /t30 oar 1(v Sly
Assessed value of real property as of Mortgage/Contract'indebtedness unpaid as of - Mortgage I Contract indebtedness unpaid as of Is the applicant the sole
assessment date,currant year assass,at date,and year data of application legal or equitable owner?
7 -7 C50() ❑ Yes ❑ No
If no,what is his I her exact share of interest? If awned with someone other than spouse,indicate with whom
•
If name on read is different than that of applicant,indicate below: Is the property in question:Annually Assessed
0 Real Property ❑ Annually Assessed
Mobile Home(IC 61.1-7)
Naze of mortga - - -- -- - - - .
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•
Name of assignee or other owner or holder of Mortgage '
Address of assignee(number and sheet ctrl:state,and ZIP c--"-
Does applicant own property in any tf yes,what county? - 1 I _ -a 6 I a 9 ,tequested If yes,state amount of deduction
Iindiana U? ❑Yes ❑No - LO n / ) ❑No
A person IS nOt entiffed to this deduction unless the per recorder's office(including any home equity fine of aec --� '� '✓� ¢��`(_ Hue basis for the deduction.
in the county .
Deduction approved in the amount of (Y11--- Lc J' 9x' '
20 20 20 1 20 l 20 -� - 20 20
Signature of County Audito County Date(month,day,year)
I 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.
S / tee
owner's full name) ll p � y//� Data(month,day year)
I nth �� —1 �- O ri+MRY i
Ftdl ddress of applicant(number and e,and ZIP
X I0 / 5 ,.e,24` 9 76 76
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,dry,state,and ZIP code)
The penalties for perjury can include imprisonment up to two and a half years and a free not to exceed$10,000.
RECEIPT FOR RUNG STATEMENT OF MORTGAGE OR v j ifrQ�j'-wa-y'J?' �;
of applicant .r . . ...-- ..Iwr,! i I
(am'^�f�/, r�p�� :MTi >''
' L1/ !♦ � / " ' � 7t'..0 Al 'i:. -. '_ � /alp . i• ELI _
*if Dad(moth,day,year) Amount of- .!F�:.. — �� 1 9 r s.-:.
--
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K e y n u m b e r/legal d e s c r i p ti o n
&6/7-07-'5`0/ Goa "3�oQ Ss seat
Signature m/County Auditor/CounptRaconies Canty GIBSON COUNTY - h•day.year)