Mortgage_Tenbarge (3) STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS Court Township Year
't1 FOR DEDUCTION FROM ASSESSED VALUATION
t. - State Form 43709(R13l 10-15)
Prescribed by Department of Local Government Finance • l; ...
INSTRUCTIONS: - ' F gait.
To be filed in person or by mail. Form filed with:
Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought dd ,,�fHH
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property R ' $ Lj jI County 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•I nty.
whem the properly is located during the twelve(12)months before March 31 of each year the deduction filth•r .—�/rt11,i�
See reverse side for additional instructions and qualifications.
GIBSON COUNTY AUDITOR
Appian) fir or contact buyer see
tes7 -c)o9 ? o ( 6. 5O3 /
Assessed value of real property as of I Mortgage I Contract indebtedness unpaid as of Mortgage I Contact indebtedness unpaid as of Is the applicant the sole
assessment data,cement year assessment date,current year date of application legal or equitable owner?
89 (7o 0 ❑ yes ❑ No
If no,what is his I her exact share of interest? If owned with someone other thin 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 ❑ Annually Assessed .
•
Mobile_ bie Home(IC 6-1.1-7)
Name of mortgagee or contract seller
L 7-F of
Address of mortgagee or contact seller(number and sheet,city state,and ZIP code) -- __
Name of assignee or other owner or holder of mortgage O 4 y`l.l.._
J
Add of assignee(number and street,city,state,and ZIP cove) kQ, ".
. `I/7 Nf 1 - y -// I , 080 A L L d . �� —
Does applicant own property in any If yes,what county? What Taxing District?. Has t t, 5 9 ' r I 1/
other on pr 1
in Indiana? Yes ❑No .curie /
A
—
person is not entitled to this deduction unless the person has a balance on the person's mo a O i `e ` S O 3 fly recorders office(including any home equity line of credit that is recorded in the county recorc l
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 1 contract buyer of the aforementioned property on date application is filed.
Signature(owner's • )
Date(month,day,year)
(Wan c�
Full r nt address (number � i e,and ZLl 05
J I I ft- v ,.Pc 1 -q`, 91(CSC!
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 skeet city,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.