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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
Th; FOR DEDUCTION FROM ASSESSED VALUATION
State 43709(R13/
Presrnbe d by Department o f Local Government Finance FILED
WSTRUC7IONS:
To be filed in person or by mad. Form filed with:
Filing Dates: 1) Real Property.Must be completed and dated in the calendar year for which the deduction is sought. Q-�7n'J
Must be filed or postmarked with the County Auditor or County Recorder of the corny where the properly isJ U N LI my Auditor
located on or before January 5 of the irnuwdiately succeeding calendar year.
2) Mobile/Manufactured Homes not assessed as Real Property.Must file with the County Auditor of the co u corder
where the property is located during the twelve(12)months before March 31 of each year the deduction is s See reverse side for additional instructions and qualifications. G I BSO N COUNTY AUDITOR
Applicant(owner Or Wryer-Sae restn uses! )•- ,
Taxing Drril
-IZ- 1'1' - ID( -OD -44,1 -1)02P - e e g5ihrt
Assessed value rte taopeny as of Mortgage/Contract cWetgedness unpaid as of • Mortgage/Contract indebtedness unpaid as of Is the applicant the sole
assessment dare,anent year assessment date, date of application legal or equitable owner?
❑ Yes ❑ No
tf no,what is his I her exact share of interest? If owned with someone other than axeim,indicate with whom
If name on record is different than that of applicant indicate below Is the property in question:Annually Assessed
❑ Real Property ❑ Monte Home 6-1.1-7)
Name of mortgagee or contract seller .�
Motile rt
Address of mortgagee or contract seller(number and street city,state,and ZIP code)
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Name of assignee or other owner or holder of mortgage '
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Address of assignee(number and street my,state,and ZIP code) •
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
omn Ind a ? ❑Yes ❑ho anent ?fo ❑Yes El 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 fine of credit that is recorded in the county recorders office)that is the basis for the deduction.
COUNTY AUDITOR "
Deduction approved in the amount of:
•
•
20 20 20 20 20 20 20
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Signature of CamtyAUdtw Canty Date(monde 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/ buyer of the aforementioned property on date application is filed.
S r?amel I Data(mardh,day,year)
F resident a Tess of applicant(number and street city,state,and ZIP code)
Person authorized by duty executed Power of Attorney or by IC 6-1.1-12-0.7 Date(month,day.year)
Address of authorized person (number and street dt):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.