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STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
.,#'��$� FOR DEDUCTION FROM ASSESSED VALUATION $
•, i State Form 43709(R13/10-15) R n
Prescribed by Department of Local Government Finance J /
INSTRUCTIONS: _ . File Mark )O_?a- ts):
To be filed in person or by mail O C T , R fi,
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 Co my Auditor
located on or before January 5 of the immediately succeeding calendar year. ,,;_ ''l� `�w1 1 my Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of ttf��e�cCgqrrny�
where the property is located during the twelve(12)months before March 31 of each year the deduc&iI74bd3:. C 0. - . : o -
See reverse side for additional instructions and qualifications.
Applicant(owner or contract on reverse
R0�t ak 't . c fv ies _
Taili(in�nng�g'',,Diis��tri��a Key[�number?/legal ldeespscdption r-� �+�,.1 Re
cord number page number
Asus•wsed wak`aa(realpmperty as of d�\1 lS lDt O00 0di -oe/Contract indebtedness unpaid as of Mortgage/ar r Q Cp t un id tett Ls the m
the sole
assessment date,amend year assessmentsss date,current year diat of application .
S'i O00 -- . ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned wO someone other than spouse,indicate with whom
If name on read is different than that of applicant,Sicate below. Is the in hu• 31Name of mortgagee or contact seller (IC 61.1-�
IN)G.n IliAlL Ili— P1 °1/4.- C , JUL 2018 0 rb
Address of mortgagee or contact seller(number and street dry,state,and ZIP code) J/1N�
Name of assignee or other comer or holder of mortgage !w M4 > nif N.
GIBSON COUNTY AUDITOR
Address of assignee(number and street city,state,and ZIP code)
Does applicant own properly in any If yes,what county? What Taxing District? Has this deduction been requested If yes,state amount of deduction
in Indiana? ❑yes ❑No cur on rent yea?perty 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 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 1 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 1 contract buyer of the aforementioned property on date application is filed.
Sig re(owner's tut name) • Date(month,day,yearl
k urgie,a c,u.� -1- 1(3- 1
Full resident address C'((nuumber and
tst Beet city,state,and ZIP code)
k
Person 10 Suter edby dulexecuted Power of Attorney``Wor t�O.1-124.7 Date(month,day,year)
Address of authorized person (number and street lily,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. . - - --.-