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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
**,,,e-; FOR DEDUCTION FROM ASSESSED VALUATION
Stale Form 43709(R13 t 10-15)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
To be filed in person or by marl. . i '1>. ' : .
Filing Dates: 1) Real Property.Must be completed and dated rn the calendar year for which the deduction is sought I I
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is t •.,. '•• 1 ditor ,
located on or before January 5 of the immediately succeeding calendar year.
2) Mobile I Manufactured Homes not assessed as Real Property.Must file with the County Auditor of the Coun 1J f4 ij7017�y Recorder
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse We for additional instructions and qualifications. •
yikAiiiiker-
ApptraM(owner ... , -see resinCAOns on reverse Q /,�,,Q f��
A. •� J 4- ) �I [ 'UC.000/Y\ GIBSON Cr):'wry p firm-na
Taxing District i number/legal Record number Pgje hM1Ber
• '. _— 1-a1- on-6011• 62 ' Cal /7 a5s6
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of - Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment dale,and year date,currentyear` date of appfaion legal or equitable owner?
d IJ�F; ) ❑ Yes ❑ No
If no,what is his/her exact share of interest? 4 . if owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant,indicate below. Is the proper•m ouestion:Annually Assessed
❑ Real P �� ` - --°-Assessed
Nam of mrtgag�o contract seller �.LS I �^r�'E� s.
Address of mortgagee or contact setter(number and street,city,state,and ZIP code) �.t �
Nam of assignee or other owner or holder of mortgage ' f 6J
j'••
Address of assignee(runner and street,city,state,and ZIP code)
Does applicant own property in any If yes,what county? - What Taxing District? Has this deduction been requested If yes,stale amount of deduction
other county in Indiana? ❑Yes ❑No - current for ❑Yes ❑No
A person is not entitled to this deduction unless the person has a balance on the person's mortgage or contract indebtedness that is recorded in the county
recorder's office(including any home equity Ens of credt that is recorded in the county recorder's office)that is the basis for the deduction.
COUNTY AUDITOR •
Deduction approved in the amount of:
20 20 20 20 20 20 20
Signature of CowdyAudda County Date(morph,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/contract buyer of the aforementioned property on date application is fled.
Signatures fug name)) Date(nnordh,day,year)
n------
11 ..1,,ecy/
Full resident of (number
city, q oodVQ o Ai/no . 1• t 4-16,7a
Person authorized by duty exacted Power of Attorney or by IC 6-1.1-12-0.7 Date(maVh,day,year)
Address of authorized person (number and street,ofy,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. - _ _ -