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;a_� STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR DEDUCTION FROM ASSESSED VALUATION
)': State Form 43709(R13110-15)
Prescribed by Department of Local Government Finance
INSTRUCTIONS: File Mark
lb 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
Must be filed or postmarked with the County Auditor or County Recorder of the county where the property is 0 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 Pie County Auditor of the county
where the property is located during the twehe(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
Appeant contract buyer-see resdirions`o_n reverse side)
OTh Pag
A # eMpmperly as of Mortgage/Contract indebtedness unpaid as of Mortgage/ ct indebtedness unpa t of Is applicant the sole `
assessment date,current year assessment date,current year date of ono!' hop 4 O DO legal or equitable owner?o ElEl(5 J 1(�� Yes No
o.ff n what is his/her exact share of interest? If ovmmed with rme other than spouse,in to with whom
If name on record is different than that of applicant indicate below Is in question_❑ M Annually M.cpcspd
Mobile
Property ssessed Home(IC 6-1.1-7)
Name of mortgagee or seller i I ^ WE . F 1 �J r ,1
Addrea of gageeg cork (number and street dly , LP code)
43 S Rac Q Cup 1 1 2018
Name of assignee or other owner or holder sit • P
e
Address of '.io lrrl
assignee(number and street ply,state,and ZIP cede) '"'....iiiivv��llllrr����1 N4,
GIBSON COUNTY AUDITOR
Does applicant own property in any If yes,what county? What Taxing District? Has this ty ,-, on properlydeduction been requested If yes,state amount at deduction
otherin Indiana? ❑Yes 0 No current year?for ❑Yes ❑No
A person is not entitled to this deduction unless the pa O ( -7 _ c, 50 G debtedness that is recorded in the county
recorder's office(including any home equity line of ore / e basis for the deduction.
Deduction apptu.ai in the amount ot Drawer NO
20 20 20_ Card NO. 20 20
Signature of County Auditor Date(month,day,year)
I
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 tiled.
1.., re(owners e) Date(month,day,year)
f I Litt Mt, Date
C1-10Ag
-`resident address oLepVppli,,c\a�ntt((numbQ and pty_y``stL_a(tea d ZIP
ZIP code)
•
Person authorized by duly executed rawer o by IC 6-1.1-12e.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.