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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
kk :i FOR DEDUCTION FROM ASSESSED VALUATION
4'° State Forth 43709(R13/10-15)
Prescribed by Department of local Government Finance h
ry ,,:o
INSTRUCTIONS: y-y ,/ i
To be filed in person or by malt JL J ir '�, :
Filing Dates 1) Real Prope#y Must be completed and dated in the calendar year for which the deduction is sought �nnl.,
Must be filed or postmarked with the County Arffitor or County Recorder of the county where the propertyr 2 7 2g County Auditor
boated on or before January 5 of the immediately succeeding calendar year. LJ County Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the properly is located during the twelve(12)months before Mardi 31 of each year the deduction._ =• t ri
See reverse side for rtonal instructions and qualifications. I V'nAllr
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Applicant(ownwwcon -ace ra•�'''•,on l- ' •-lull IA vet GIBSIN COUNTY AUDITOR
Tarmng District Record number Page number
-1Q- r . -400- DOa- c�3 s I ,3. G2
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage/Contact indebtedness unpaid as of Is the applicant the sole
assessment date,canard year assessment date,current year date of application legal or equitatie owner?
15 of Crib ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of augment,indicate below. Is the pngnsty in question:Annually Assessed
❑ Real Property ❑ Annually Assessed
n Mobile Home(IC(rt.1-T)
Name of mortgagee or contact seller f(:5j'(3tz. y�` /f` -
Address of mortgagee or contact setter(number and street city,state,and ZIP code) 1 - ._
Name of assignee or other owner or holder of mortgage 15119113 V 5-1
Address of assignee(number and street dry,state,and: ••••-
Does applicant own property in any If yes,what county f� 48- , an requested If yes,state amount of deduction
other in Indiana? ❑Yes Dm" Card NO ••• ••• >s. ❑No
A person is not entitled to this deduction unless the, _ct indebtedness that is recorded in the county
recorder's office(including any home equity line of c..,....„A.u(cwiueu in me 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 County Auditor County • Date(month,day.year)
I f 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
ow I ntra uyer of the aforementioned property on date application is filed. /( �y)a
name) Date/ D day gar)
—I A)
F o address O d a)>pr>caq a 5 at};state and ZIP code n
Culy (-1) �� Imo/ l d=(
Person authorized by duly executed Power of Attorney or by IC 6i1.1-124.7 Date(month,day,year)
Address of authorized person (number and street 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.