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sue, STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Year
FOR DEDUCTION FROM ASSESSED VALUATION
i Srfa Form 43709(R13(10-15) J
Prescribed by Department of Local Government Finance Differ INSTRUCTIONS: Differ: I .
To be filed in person or by mat. Form filed with:
FIfing Dates: 1) Real Property:Must be completed and dated In the calendar year for which the deduction is sought.
Most be filed orposhnadred with the CountyAuddor or County Recorder of the county where the property" I . , •. •itor
located on or before January 5 of the immediately succeeding calendar year. GIBSO CO ie'Ienf t u Recorder
2) Mobile/Manufactured Homes not assessed as Real Property.Must file with the County Auditor of the ll ITO
where the property is located during the twelve(12)months before Mardi 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications. •
Applicant;o r ameact buyer-seen on reverse side j /// g
5 2t&o ilia description
—O00. a�'d-Do? R llo• yaS
value chard property as of Mortgage/Contract indebtedness unpaid as of . Mortgage I Contract indebtedness unpaid as of Is the appicard the sole
assessment date assessmerd date,anent year date of application// co legal or equfable ovmer?
11 7 6 El Yes ID No
If no,what is his I exact of interest? If owned with someone other than‘vyv.ca,indicate with whom •
If name on record is different than that of applicant,indicate below: ,,Iss Is the property in question:Annually Assessed
/ 'Real Property ❑ �ay Assessed 1.1-7)
Nam of mortgagee or contact saner (� //////------��1� zo .
Address of mortgagee or contract nwnnbbetry-ann crsstreet state,and a) Si
Name of assignee or other owner or holder of mortgage '
Address d assignee(number and sheet,rdy,state,and ZIP cx cz/�p ' n_- S 11 r�` . (�
Does applicant own property in any If yes.What county? pJ 1 e V t;•Vh L. ld C tt�.'(‘ \0.. {Z used If yes,state amount of deduction '
in Indiana? DYes El No - hm�S -4c 0 No
A person is not entitled to this deduction unless the pets (� O roes 1 C is,v� debtedness that is recorded in the county '
recorder's office(including any home equity One of reed V I v� . c.0 1/4,4_,rtnPy a basis for the deduction.
a\ C1 t8at,.ou 1a- 11-N,
Deduction approved in the amount ot.
20 20 20 20 20 20 20 •
Signature of CoumyAuditor County Date(month,day.year) •
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/contrail buyer of the aforementioned property on date application is filed.up T Date(month,day yew)Full resident addr�of appticand(nu a 4•-.-- sty,st and ZIP code)
�1q� 6 Cuvime (j(�i11 , Knt'e TT\( g7Q O
Person authorized by duly exeaded Power of Attorney or by 6-1.1-12-0.7 Date(month,day,year)
Address of authorized person (number and Meet,caly,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.
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