Mortgage_Romain �:� . STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS ' County Township Year
kw ,r FOR DEDUCTION FROM ASSESSED VALUATION
✓,: State Form 43709(R13110-15)
`— Presrnbed by Department of Local Government Finance
INSTRUCTIONS: . _ TFiI- May
To be filed in person or by mail. g .. .i. =- -"�r
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 D E r ,� /I I�p
aty Auditor
located on or before January 5 of the immediately succeeding calendar year. ] VOunty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property:Must file with the County Auditor of the county
where the property is located during the twelve(12)months before March 31 of each year the deduction is snugly.
See reverse side for additional instructions and qualiifrcations.
Appik-o�ovmer r• r .-see eS joy n GIBSON COUNTY AUDITOR/
Taxing District Key number
`-[ t0 a,"legal
3 description
o- '(oo a . 9D1, --Da 4 03 3 r 9 /
Assessed value of real property as of Mortgage I Contract indebtedness unpaid as of Mortgage I Contract indebtedness unpaid as of Is the applicant the sow ike
assessment date,current year assessment date,arrant year date f legal or equitable owner?
�(/ _ ❑ Yes ❑ No
If no,what is his/her exact share of interest? If owned with someone other than spouse,indicate with whom
It name on record is different than that of applicant,indicate below Is the property in question:Annually Assessed
❑Real Property 0 Annually Assessed
I Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller L 1 Qi 4r1 lJ-/•`^ [�
Address of mortgagee or contract seller(number and street dry,state,and ZIP code) �
Name of assignee or other owner or holder of mortgage
Address of assignee(number and street.dry,state,and ZIP code)
Does applicant own property in any If yes,what county? What Taxing District? Has this deduction been regtmsted If yes,state amount of deduction
�iaanna?nty ❑Yes ❑No ' aaiirrent year?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 recopied in the county
recorder's office(inducting 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 u Si tt)e penalty of perjury that the above and foregoing information is true and correct and that the applicant is a resident of Indiana and
/co glib uyer of the ntioned property on date application is filed.
i re ) Date(uaatdr,day,year)
Full t o 3 applicant/number gstreet,+ ZIP L 4- c73 c r
Person authorized by duly executedPower of Attorney or by IC e-1.1-12-0.7 Date Wait I•,day,year) •
•
Address of authorized person (number and street dry,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.