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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
FOR0DEDUCTION FROM ASSESSED VALUATION
.:; '.•a State Fonn 43709(R13110-15)
Presatbed by Department of Local Government Finance
INSTRUCTIONS: File Mark
lb be filed in person or by mail. Form filed with:
Filing Date& 1) Real Properly 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.
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county 0 County Recorder
where the propedy is located daring the tweAe(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
t( rt contract -see resvicmpAKr curse 'side)
. APPUD - number/legal description ption Record number Page number
.26 -\-1-0Z--1-ico-ool-�.72-1 -U�1 2-10 l b 4101
astera refa.of leaf as of Mortgage/Contract indebtedness unpaid as of Mortgage/Contract indebtedn paid as of Is the applicant the sole
arrmJmt assessment date,anent year date cation legal o ` ble owner?
r � ^^e-�� . Yes ❑ No
If no,what is his I her exact share of interest? If owned with eone ostler spouse,indicate with whom
If name on record is efferent than that of applicant,indicate below. property in question:Annually Assessed
Real Property 0 AnnuafyAssessed
• AIpt71)g Home(IC 61.1-7)
Name of mortgagee or contract seller � �p�/®9
ra C�c l (`(lN - R �Yj
Address of mortgagee or contract seller(number and street city,state,and LP code)
OCT 162018
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street city,state,and ZIP code) o. . Ait
GIBSON COUNTY AUDITOR
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
other county on property for
in Indiana? ❑Yes ❑No anent year? ❑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 line of credit 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 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/contract buyer of the aforementioned property on date application is filed.
Signature( full name) Date(month,day,year)
Full resident ad of appri (numbered sbee state,and ZIP code)
Person authorized by duly executed Power of Attorney or b)/ICG1.1-12-0.7 / 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 S10,000.