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ax. STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
` ' FOR DEDUCTION FROM ASSESSED VALUATION
Y State Form 43709(R13/10-15)
— Prescribed by Department of Local Government Finance
To INSTRUCTIONS:
person
g
ts
To be filed in pers or by marl. I�rf
Filing Dates 1) Real Properly the
Must be completed and dated in 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 ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. (1 T 2 p 04unty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the courg•C
where the property is located during the twelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualifications.
t(owreror contract drys-- resma on side) ;4
(rt.�(.-N I(e�m m� I� �\ GIBSON COUNTY AUDITOR
Taxarxg Ostr�t r Key,rrymb�/l tl 9 O0 — 00 J t`� ' ,�^� Record numbs()) Pag num er
Assessed `value of real property as of n/(/`/(_J ^Mont`jgaage I Contract indebtedness unpaid as of Mortgage I`Co'LContraact~/ indebtedness unpaid as of UYIs the applicant thesole
assessment date,current year assessment date,current year dafe,of-aapl- i -�.,w - • legal or equilab!e owner?
Il Cyy (//1 f//TD/Vl ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone cher than spouse,indicate with whom
ff name on record is different than Nat of applicant,indicate below. Is the property in question:Annually Assessed
Q S ❑Real Property ❑ Annually Home
(IC(IC 6 a 6
Mobile 1.1-7)
Name of mortgagee or contract seller
Address of mortgagee or contract seller(number and street,ray,state,and ZIP code)
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street,city,state,arY-"n--'-`- - - -
Does applicant own property in any If yes,what cou een requested If yes,state amount of deduction
other county �/�\ x
in Indiana? ❑ O\Yes ❑No Drawer NO.. v Yes El No
A person is not entitled to this deduction unless I ract indebtedness that is recorded in the county
recorder's office(including any home equity line r ^ tt is the basis for the deduction.
•. Card NO. IlJhll_Tl
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 coned and that the applicant is a resident of Indiana and
owner I contract buyer of the aforementioned p rty on date application is filed.
ZatiomwnerZilrfial me) /I Date(month,day,year)
resident f.( ')oVffC/art//roicant(nu erlan sheaf at;state.a LPcode)/1 I 01 ?
it
Co(954
Person authorized by duly executed Power of Attorney orr by IC 6-1.1-12-0.7 f1~/Pi 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.