Mortgage_Poe (3) 3. . STATEMENT OF MORTGAGE OR CONTRACT INDEBTEDNESS County Township Year
,Y`- FOR DEDUCTION FROM ASSESSED VALUATION
State Form 43709(R13/10-15)
� Prescribed by Department of Local Government Finance
INSTRUCTIONS: M
lb be filed in person or by mail. Fo I
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 ❑ County Auditor
located on or before January 5 of the immediately succeeding calendar year. D E C El CBaty Recorder
2) Mobile/Manufactured Homes not assessed as Real Property Must file with the County Auditor of the county
where the property is boated during Me twelve(12)months before March 31 of each year the deduction is sought
See reverse side for additional instructions and qualification. p
n �
Applicant(owner or contract see re�:fcaF �side)1 n � QA L21Y A11 ;�KAe,�J��u.{}�..t`�1X, (,�t, 1PY/-11 GIBSON COUNTY AUDITOR
Taxing District f T(^ —j` "— Wit - 0 Op .3( q— w') Record!$ �1C�1—.)
Assessed value of real property as of art Mortgage/Contract indebtedness unpaid as of Mortgage I contract indebtedness unpaid as of Is the applicant the sole
assessment date,current year assessment date,current year date of application q legal or equitable owner?
7 3 0- V 0 ❑ yes ❑ No
If no,what is his I her exact share of merest? If owned with someone other than spouse,indicate with whom
If name on record is different than that of applicant indicate below. Is the property is question:Annually Assessed
❑ Real Property ❑ AnnuafyAssessed
• Mobile Home(IC 6-1.1-7)
Name of mortgagee or contract seller MCC
Address of mortgagee or contact seller(number and btreut city,state,and ZI code)
Name of assignee or other owner or holder of mortgage ,
Address of assignee(number and.,beet city,state,and x'^-- - �.h—I(r P' D
onA
Does applicant own property in any If yes,what COO 0 L , ` I (-1 G ` ��h�� sen requested If yes,state amount of deduction
other county
in Indiana? ❑yes ❑No c i I�1' 6.7 0 X (es ❑No
A person is not entitled to this deduction unless It. Pt
v ` ,t act indebtedness that is recorded in the county
recorder's office(including any home equity line c ��n.� �D l CD�P�2 is the basis for the deduction.
Deduction approved in the amount of N '( kciv r 1 /
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 I contract buyer of the aforementioned property on date application is filed.
rts
/u8 e) Date(month,day,year)
e)
-ofa h t(� S-kre nd street,city e,and LOP Ha -I , ,k) Lll CY"_V
ed by duly executed Parer of Attomey or by IC 6-1.1-12-0.7 ` 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. •
